How EMR Coding Guidance Prevents Medical Necessity Denials
Keisha Downes, Vice President of Middle Revenue Cycle at Beth Israel Lahey Health, describes how medical necessity denials often trace back to a documentation gap between what clinicians record and what payers require. As policy changes and coding rule updates accelerate, proactive management becomes harder. The old answer, placing a coder next to a clinician, is no longer practical at scale. Her team's approach is to embed real-time guidance directly in the EMR: pop-up alerts that flag missing laterality, catch inappropriate use of family history codes, and prompt clinicians to provide a specific diagnosis. That real-time signal helps clinicians document in a way that aligns with certified coder standards, reducing medical necessity denials and preventing unexpected patient financial liability downstream.
Key Takeaway
Medical necessity denials caused by clinician documentation gaps can be significantly reduced by embedding real-time ICD-10 coding guidance in the EMR at the point of care. Bringing coder-level intelligence to clinicians in context is more scalable than any post-documentation review or appeal process.
“Clinicians are not coders, and we have to find a way to give them the tools that they need so that they can align a little bit better with the skill set of a certified coder.”
Keisha Downes, Vice President of Middle Revenue Cycle, Beth Israel Lahey Health
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