Medical Necessity Edits

We provide class-leading applications and content to hospitals and clinics — and, combined with our vendor partners, more than 700 million claims run through partner solutions using our data each year, and we take that responsibility very seriously.

VitalIntelligence: The New Standard for Medical Necessity

Bring our Industry Leading Edit Logic To Your Solutions

The core of our business is effectively developing, structuring, and maintaining regulatory and coding content. Our Best in KLAS solutions’ distinctive power is based in the accuracy, richness and depth of that content, and our ability to present it with clarity in a variety of real-world, working contexts.

VitalIntelligence helps our vendor partners focus on their businesses — everything from EMR/EHR software vendors to clearinghouses and revenue cycle vendors — without getting caught up in the time-consuming complexities and ever-changing terrain of regulatory rules, regulations, and logic.

With VitalIntelligence, our partners can embed this richer, always up-to-date content in their own solutions—creating significant, measurable benefit for your users.

Better Edits, From A Deeper Foundation

With ICD-10, the industry went from a potential pool of approximately one million medical necessity edits (MNE), to over 20 million and growing. We built our solutions on this far-richer foundation, and we remain unique in our ability to manage this complexity, providing our users and partners medical necessity edits that accurately reflect the multi-factor logic of today's complex regulatory environment.

Seeing 3-D: More "Green," And Far Less "Yellow"

Most MNE vendors don’t have capabilities to handle today’s complex edits, and fail to process complex code combinations. This often gives you false “green lights,” or "red lights" – both harmful and costly. The common "yellow-light" outcome is also costly, as it means you have to do the research and make a determination yourself, or guess.

Our proprietary edit engine can process complex edits (logic loops) that look past the simple code relationship to show that either additional diagnoses, HCPCS, or an ABN is needed. We see this as going from 1D data to 3D medical necessity validations. You will experience it as fewer warnings, and more accurate pass and fail results that includes messaging derived from the policies. This means less time spent on research and more accurate reimbursement.

Regulatory Content Updated Weekly

Our edits are updated on a weekly basis rather than the industry norm of quarterly, further enhancing accuracy. We also provide our users with a weekly report of detailed coverage changes, making it easy to identify changes that are pertinent to your users.

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Richer Content, Delivered How You Need It

Having invested over 20 years of expertise and resources to effectively build and maintain this multi-dimensional logic grid, we turned our energies toward delivering and presenting this information in the most convenient and usable form for all of our various partners. We work hard to assure that our data is up-to-date and reliable, but we're equally obsessed with assuring that both the information and decision-guidance we provide are intuitive and easy to follow. We're able to deliver our data — and the complexity that creates so much value — in a variety of forms to meet your specific needs.

Compared to others of its kind, VitalIntelligence is much more comprehensive. Our users can quickly customize data and access all of the information, providing an invaluable difference.

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The Data We Provide

Here's a high-level overview of the data assets we provide:

Regulatory Data

  • CPT Codes
  • HCPC Codes
  • ICD Codes
  • LCD/ NCD articles, policies

Proprietary Data

  • Coding Crosswalks
  • ICD Terminology Search
  • Revenue Code Crosswalks
  • Modifier Crosswalks

Claims Checking

  • Medical Necessity Edits
  • Correct Coding Initiatives
  • OCE / OPPS Calculator
  • MCE / IPPS Calculator

As You Like It: Format Flexibility

VitalIntelligence provides data in a wide range of file formats, and we're well equipped to handle customized formats and unique delivery-cadences. We can seamlessly integrate into your organization’s existing solutions via the VitalIntelligence API, through HTML Controls, or, if you prefer, through delivery of raw data files.


We're flexible, precise, and thorough, no matter what delivery method(s) you chose.

Raw Data Files

Access files on a scheduled basis in either a flat (CSV) or XML file format.

LCD/NCD/NCCI/MUE
CPT/HCPCS Reference
ICD-10 Reference
ICD-10-CM
ICD-10-PCS
Code Mapping & Crosswalk
CPT to ICD-10 PCS
CPT to HCPCS
Fee Schedules
RVUs
Ambulance
DME
MPFS
OPPS
Lab

Web Services API

Enabling integration of our content with your own UI and functionality.

ICD Sherpa
LCD/NCD and CCI Validation
CPT/HCPCS Search
Code Packets
DRG Grouping
ICD-10 Code Maps
ICD-10 Coding Guidelines
Outpatient Prospective Payment System (OPPS)

HTML Controls

For referential coding functionality with built-in navigation logic for easy deployment to end-users.

iDocuMint (Code search)
VitalKnowledge (Code lookup and referential)
Code Referential (Referential info panel for any/all code sets)
Code Validate (medical necessity edits)

Get started with VitalIntelligence

For a comprehensive understanding of the efficiencies you can gain from our proprietary data, and to see the superiority of our medical necessity edits, schedule a personalized demonstration of VitalIntelligence. Bring your most experienced experts: they'll see the difference right away.

Schedule a Meeting