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Medical Coding and Billing Articles

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Be Prepared – For the Social Security Number Removal Initiative (SSNRI)

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The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019.   Beginning April 2018, CMS will begin sending out new Medicare cards to Beneficiaries.  Replacing the Social Security Number will be the Medicare Beneficiary Identifier or MBI.  Be ...

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Sale of Protected Health Information (PHI)

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To more fully understand federal regulations regarding the sale of PHI, review the comments and responses.

Tags:  Topic: HIPAA   

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Don’t Overlook Diagnosis Codes During Coding Audits

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Coding auditors focus much of their attention exclusively on C.P.T. codes during the review process. After all, codes reported for E and M visits, surgical procedures, and diagnostic services are what generate revenue to the provider or facility. Even more importantly, errors in reporting these services are frequently what give ...

Tags:  Topic: Auditing    Topic: ICD9v3 Coding   

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Treating Diabetic Patients in Your Office?

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CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs. Remember that prior to providing ...

Tags:  Topic: Auditing    Topic: HCPCS Coding   

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The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims

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This tip may contradict everything you've heard before. However, if you consider it with an open mind, you will see that it is an accurate characterization of the law, and it is also consistent with common sense. The phrase "If it isn't written, it wasn't done" is repeated so commonly ...

Tags:  Topic: Auditing   

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Outpatient Physical Therapy Changes Effective June 13th, 2017

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Our friends in clinics operating in Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or in a rural area have long struggled with how to cover Physical Therapy services when a therapist is on leave, vacation, or in event of medical leave. The Centers for Medicare and Medicaid ...

Tags:  Topic: Auditing   

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Diagnosing, Documenting, and Coding for Radiculopathy

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Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in ...

Tags:  Topic: Auditing    Topic: ICD10CM Coding   

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Neck: Supple

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I am allowed the opportunity, through our wonderful NAMAS members and bootcamp and conference attendees, to educate all walks of auditors and compliance professionals. These include not just compliance auditors and divisions in healthcare, but also auditors on the carrier side. As I do, I see the good fights on ...

Tags:  Topic: Auditing   

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Sanction Screening and Evaluating Employee Suitability: The New “Seventh Element” of Compliance

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The recently issued Resource Guide for Measuring Compliance Program Effectiveness, the product of roundtable discussions by Office of Inspector General staff and compliance professionals, emphasizes the importance that the OIG places critical role of exclusion screening and background checks in compliance. Issued in March, the Resource Guide re configures the ...

Tags:  Topic: Auditing   

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Laceration Repairs

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Auditing laceration repair is generally an adventure. Most of my auditing work is reviewing the work of our coders rather than providers, but I have audited physicians as well. My present position has limited communication with providers, however we do attempt to get important information back to our clients for ...

Tags:  Topic: Auditing    Topic: CPT Coding   

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The Difference Between Leadership and Management

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"The best leader is the one who has sense enough to pick good men to do what he wants done, and the self-restraint to keep from meddling with them while they do it." -Theodore Roosevelt When a person wants to secure a topnotch position in their company, are they willing to ...

Tags:  Topic: Auditing   

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Consultation or Transfer of Care, What are the Differences?

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According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...

Tags:  Topic: Auditing    Topic: CPT Coding   

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Ashby’s Law of Requisite Variety; A Lesson in Preparedness

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Have you ever wondered why grandparents have so much more fun with their grandchildren than they did with their children? Or why they have so much more fun than their children have with their children? It's the same reason why some organizations move through crises like a knife through butter ...

Tags:  Topic: Auditing   

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Getting Serious About Your Practice’s Compliance

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By now, hopefully most (if not all) practices know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan for most of this decade. In its own words, the OIG believes "that a healthcare provider can use internal controls to ...

Tags:  Topic: Auditing    Topic: Compliance   

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Penalties Under the False Claims Act Have Risen for the Second Time Within the Last 12 Months

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The False Claims Act is the primary civil enforcement tool utilized by the U.S. Department of Justice (DOJ) to address false claims submitted to government programs and contracts by individuals and entities. The statute was first passed during the Civil War in 1863 in an effort to address the wrongful ...

Tags:  Topic: Auditing   

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Auditing Neurologic Exams: Tips for Success

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As an auditor, you may be asked to audit encounters that occur in various multi-specialties. It can be difficult to remember the ins and outs of each specialty, especially if you do not consistently work in a particular specialty. Neurology is one of those specialties that can appear daunting due ...

Tags:  Topic: Auditing   

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Documentation: Carrying Forward or Ineffective Use of Templates

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I often receive questions such as the below from our members regarding E&M scoring: "I have heard that if information is 'cloned' or 'moved forward' from a previous visit, we should not count that info in scoring. However, I have also read that if a provider moves the info forward and ...

Tags:  Topic: Auditing    Topic: CPT Coding   

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Focus Audit Results on the Documentation, Not the Encounter

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As an auditor, your job is to assess the quality of the documentation created by the provider to determine whether it meets the requirements to bill the code assigned to the service. This task often set us up a potentially adversarial role with the provider, particularly when it comes to ...

Tags:  Topic: Auditing    Topic: CPT Coding   

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Profit Depends on Efficiency

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To us, the most fascinating thing about process improvement within a medical practice is how it has a clear clinical counterpart: differential diagnoses. In a typical scenario, a patient presents with a chief complaint ("I don't feel well"), and it's the provider's job to figure out just what is wrong ...

Tags:  Topic: Auditing   

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New payments for Psychiatric Collaborative Care Services (COCM) from Medicare

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Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017. Any condition new or pre-existing behavioral health or substance use disorders are eligible.  Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well. Using the ...

Tags:  Specl: Behavioral Health|Psychiatry|Psychology    Topic: HCPCS Coding   

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Past Articles

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The following articles are published here and elsewhere on the Internet. If you would like to publish one of these articles on your website, please contact us and let us know which article you would like to publish and where you will be publishing it.

Articles: ICD-10

Articles: Medical Coding

Articles: Medical Billing

Articles: Medical Billing and Coding (General)


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