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"Claims Processing" & "Auditing" Articles
Click on the title to see the article summary and a link to the full article.
November 18th, 2020
How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
By Raquel Shumway | Published November 18th, 2020
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
November 18th, 2020
Cross-A-Code Instructions in Find-A-Code
By Raquel Shumway | Published November 18th, 2020
Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
September 1st, 2020
Not Following the Rules Costs Chiropractor $5 Million
By Wyn Staheli, Director of Research | Published September 1st, 2020
Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?
August 5th, 2020
Coding with PCS When There is No Code
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 5th, 2020
ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn? To the guidelines, of course! There are ICD-10-PCS guidelines just as ...
July 14th, 2020
Are NCCI Edits and Modifiers Just for Medicare?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
July 1st, 2020
Understanding UCR Inpatient Fees used on DRGs
May 18th, 2020
Packaging and Units for Billing Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 18th, 2020
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
April 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020
Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
March 21st, 2020
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2020
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
February 19th, 2020
Q/A: Did Noridian Stop Covering the M99.0- Codes?
By Wyn Staheli, Director of Research | Published February 19th, 2020
Question: I heard that Medicare Noridian Jurisdiction F (Alaska) has been denying claims with M99.00, M99.01, M99.02, M99.03 etc codes when billed with the CMT CPT codes. Did Medicare change their policy?
February 10th, 2020
A 2020 Radiology Coding Change You Need To Know
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 10th, 2020
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
January 9th, 2020
Who Knew? There are Three Types of Add-On Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 9th, 2020
Using add-on codes with HCPCS/CPT is not as simple as 123! Although there are three different groups of add-on codes assigned by CMS, these are used to identify code edits. It is easy to see the add-on code with some codes; we can see the instructional notes and phrases such ...
January 7th, 2020
Denials due to MUE Usage - This May be Why!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 7th, 2020
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
December 13th, 2019
What did I do today?
By Namas | Published December 13th, 2019 - Last Review/Update January 7th, 2020
What did I do today?
Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...
November 19th, 2019
Medical Insurance Coverage for TMJ Disorders (TMD)
By Christine Taxin | Published November 19th, 2019 - Last Review/Update November 20th, 2019
It is agreed that TMJ disorders should be covered by insurance. There are often questions whether it is covered by medical insurance or dental insurance and where the line is that separates coverage.Medical Insurance typically is the primary insurance for TMJ disorders. The reason is that joints are found anywhere ...
November 18th, 2019
Documentation Tips
By Christine Taxin | Published November 18th, 2019
Documenting Medical NecessityTo receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using ICD-10 codes and CPT codes. These ...
October 18th, 2019
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
By Namas | Published October 18th, 2019 - Last Review/Update October 23rd, 2019
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
September 30th, 2019
Q/A: How Do I Bill a House Call?
By Wyn Staheli, Director of Research | Published September 30th, 2019
Question
If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form? A modifier, or something else?
Answer
Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...
August 2nd, 2019
The Slippery Slope For CDI Specialists
By Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019
Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.
Many of you in this industry are ...
July 26th, 2019
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
By Namas | Published July 26th, 2019 - Last Review/Update August 8th, 2019
Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky.
In their notice, Anthem states:
"Effective for all commercial ...
July 23rd, 2019
Tips to Preventing Audits
By Christine Taxin | Published July 23rd, 2019 - Last Review/Update July 30th, 2019
There is an ever-increasing number of dental claims that have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and billing practices. When payers identify the activities they deem ...
July 5th, 2019
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
June 14th, 2019
A United Approach
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
May 24th, 2019
What to Look for When Auditing Smoking Cessation Services
By NAMAS | Published May 24th, 2019 - Last Review/Update June 19th, 2019
What to Look for When Auditing Smoking Cessation Services
April 29th, 2019
Q/A: I’m Being Audited? Is There a Documentation Template I can use?
By Wyn Staheli, Director of Research | Published April 29th, 2019
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...
April 23rd, 2019
Let's Talk High Risk E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
April 15th, 2019
Q/A: How Many Diagnosis Codes do I use?
By Wyn Staheli, Director of Research | Published April 15th, 2019
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that?
Answer: More is not always better. You only need to ...
April 8th, 2019
Prepayment Review Battle Plan
By Wyn Staheli, Director of Research | Published April 8th, 2019
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
March 29th, 2019
Prolonged Services
By Namas | Published March 29th, 2019 - Last Review/Update April 4th, 2019
Prolonged Services
I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...
March 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
March 20th, 2019
Type of Bill Code Structure (2018-08-30)
By Find-A-Code | Published March 20th, 2019 - Last Review/Update March 25th, 2019
The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form.
Type of bill codes are four-digit codes that describe the type of bill a ...
March 7th, 2019
Date of Service Reporting for Radiology Services
By Wyn Staheli, Director of Research | Published March 7th, 2019
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
March 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
February 5th, 2019
Clinical Staff vs. Healthcare Professional
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 5th, 2019
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.
Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges.
Examples of Qualified Healthcare professionals:
(NOTE: this list is not all-inclusive, please refer to your payer ...
January 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
January 22nd, 2019
Home Oxygen Therapy
January 10th, 2019
Are You Protecting Your Dental Practice From Fraud?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
January 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
November 30th, 2018
Auditing looking between the lines
By BC Advantage | Published November 30th, 2018 - Last Review/Update January 9th, 2019
When given the task of auditing a group of charts, most often the scope of the audit is well defined. For me, there are times when my natural inquisitive nature turns on and I find my noticing the "timing" of parts of documentation. These are things that you would not...
November 9th, 2018
Billing 99211 Its not a freebie
By | Published November 9th, 2018 - Last Review/Update November 29th, 2018
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
October 19th, 2018
We've Always Done It This Way and Other Challenges in Education
By BC Advantage | Published October 19th, 2018 - Last Review/Update November 1st, 2018
As coders, auditors, and compliance professionals, we are the provider's advocates in closing the gap between what is medically necessary and what is required for documentation. Sometimes that places us in the role where we need to save our clinicians from themselves, and the patterns they have fallen into...
October 17th, 2018
Wolters Kluwer Drug Pricing
By Find-A-Code | Published October 17th, 2018
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
October 5th, 2018
Prolonged Services Its Not Just About Time
By BC Advantage | Published October 5th, 2018 - Last Review/Update October 17th, 2018
Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter.
However, a ...
October 1st, 2018
When to Use Modifier 25 and Modifier 57 on Physician Claims
By BC Advantage | Published October 1st, 2018 - Last Review/Update October 17th, 2018
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...
September 26th, 2018
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
By BC Advantage | Published September 26th, 2018 - Last Review/Update October 17th, 2018
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...
September 11th, 2018
Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement
By BC Advantage | Published September 11th, 2018 - Last Review/Update September 24th, 2018
We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...
August 30th, 2018
Keys to Successful Claims Filing
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
August 3rd, 2018
When Medical Necessity and Medical Decision Making Don't Match
By BC Advantage | Published August 3rd, 2018 - Last Review/Update September 24th, 2018
As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...
July 18th, 2018
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By | Published July 18th, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.
For ...
July 12th, 2018
Dual Medicare-Medicaid Billing Problems
By Wyn Staheli, Director of Research | Published July 12th, 2018
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...
June 26th, 2018
WHO Said ICD-11 is Coming Soon
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 26th, 2018
Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...
June 11th, 2018
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
June 8th, 2018
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
By Sharon Hoglund, CPC, CPMA, CEMC, CEMA | Published June 8th, 2018 - Last Review/Update July 3rd, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...
June 7th, 2018
The Range of Motion Conundrum
By Gregg Friedman, DC, CCSP | Published June 7th, 2018 - Last Review/Update January 30th, 2019
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
June 4th, 2018
Auditing Therapy Evaluation Codes - Not So Quick!
By Nancy J Beckley, MS, MBA, CHC | Published June 4th, 2018
New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...
June 4th, 2018
Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?
By BC Advantage | Published June 4th, 2018
When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63. The Centers for Medicare & Medicaid Services (CMS) will...
May 30th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
May 14th, 2018
TKAs to Outpatient What We Have Learned with Q1
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
May 4th, 2018
The Devil is in the Data Details
By J. Paul Spencer, CPC, COC | Published May 4th, 2018 - Last Review/Update May 24th, 2018
As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.
April 23rd, 2018
Critical Care Documentation
By Scott Kraft, CPC, CPMA | Published April 23rd, 2018 - Last Review/Update May 2nd, 2018
Critical care documentation should show critical need for the patient AND immediate action by the provider....
April 20th, 2018
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
March 27th, 2018
Maximizing Resources for ICD-10 Coding Audits
By BC Advantage | Published March 27th, 2018 - Last Review/Update April 12th, 2018
From internal reviews to external inpatient coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind....
March 26th, 2018
Avoiding D9 Denials
By Nicole, QCC | Published March 26th, 2018
The following is according to WPS.
Please make sure what is bold below is entered verbatim on the second line of the "Remarks" section. This should be the only thing on the second line of remarks:
Patient control nbr - If you are changing or adding a patient control number
Admission hour - If you are changing or adding the admission ...
March 9th, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published March 9th, 2018 - Last Review/Update April 12th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
March 8th, 2018
Documentation for Skilled Nursing Facilities
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).
March 6th, 2018
Increase Revenue by Outsourcing Medical Billing
By iSALUS Healthcare's | Published March 6th, 2018 - Last Review/Update April 12th, 2018
Many practices are starting to weigh the benefits outsourcing medical billing compared to keeping it in-house....
February 23rd, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published February 23rd, 2018 - Last Review/Update February 26th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
February 2nd, 2018
Scoring & Reporting Your Audit Findings
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published February 2nd, 2018 - Last Review/Update February 7th, 2018
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
January 31st, 2018
Developing Coding Policies for Compliance
By Marge McQuade, CMSCS, CHCI, CPOM | Published January 31st, 2018
Every physician practice depends upon correct coding and billing for their financial success. Coding drives reimbursement. All of the resources available for coding information and guidance are meaningless without the practice manager translating it into provider-specific coding policies and compliance plan. As a practice manager, you need to develop a ...
January 29th, 2018
Referring and Ordering Physician - CMS-1500 Box 17
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item ...
January 24th, 2018
Revenue Cycle 101: Reduce your Denials with These Tips
By Ranadene Tapio, MBA, CMRS, CMC | Published January 24th, 2018 - Last Review/Update March 29th, 2018
Your practice seems to be doing everything right. You have a team in place, established your RCM process and you’re submitting claim after claim – but your denial rate isn’t going down....
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 4th, 2018
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
By Find-A-Code | Published January 4th, 2018
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...
December 15th, 2017
Is Your Practice in Need of a Wellness Visit?
By Valora Gurganious, MBA, CHBC | Published December 15th, 2017 - Last Review/Update January 31st, 2018
Is your practice busier than ever, but net practice income continues to drop?
December 12th, 2017
Is Your Practice Making Costly Mistakes with The Billing?
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
You may think your billing processes are working perfectly, but even the best billing process can take more time than it should to collect and some collections are lost altogether. It could be the staff's fault or yours as the office manager, but either way it's a major problem. It's...
December 1st, 2017
Auditing the Use of a Scribe
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published December 1st, 2017 - Last Review/Update January 31st, 2018
A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......
November 24th, 2017
Inpatient critical care: When is it ok to question the medical necessity?
By Stephanie Allard, CPC, CEMA, RHIT | Published November 24th, 2017 - Last Review/Update January 31st, 2018
While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary.....
November 17th, 2017
Fear Factor: "The Unethical Business of Medicine"
By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC | Published November 17th, 2017 - Last Review/Update January 31st, 2018
I want this story that I am about to share with you to fit with the majority of clients that I represent and work with because I have represented clients with refund demands as small as $1,000 and clients who had demands greater than $30 million. This year has been ...
October 20th, 2017
PFSH Documentation: Q and A
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published October 20th, 2017 - Last Review/Update January 31st, 2018
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
October 13th, 2017
So, How Do You Decide if a Service was Provided?
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
October 6th, 2017
Your NAMAS Weekly Auditing & Compliance Tip for October 6, 2017
By NAMAS | Published October 6th, 2017 - Last Review/Update October 16th, 2017
October 6, 2017
Acronyms and Abbreviations: When You Fall Into The Grey Area
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before.
The language is unclear, the acronym(s) could mean so many different things, and it's hard to get ...
October 6th, 2017
Acronyms and Abbreviations: When You Fall into the Grey Area
By Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC | Published October 6th, 2017 - Last Review/Update February 1st, 2018
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....
September 29th, 2017
Big Data & Facility Audit Complex Reviews
By Shannon Cameron, MBA, MHIIM, CPC | Published September 29th, 2017 - Last Review/Update January 31st, 2018
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
September 15th, 2017
Copy and Paste: The Real Rules Prevail
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 15th, 2017 - Last Review/Update January 31st, 2018
Have you looked for published guidance on cloning/copying and pasting from the Centers for Medicare & Medicaid Services (CMS)? There is one published resource that provides rudimentary guidance.....
September 14th, 2017
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
September 1st, 2017
2017 Physical Therapy Evaluation & Management Codes
By Kathy Price, RHIT, CPC, CCS-P, CPMA | Published September 1st, 2017 - Last Review/Update January 31st, 2018
As you know, 2017 brought us new evaluation and management codes for physical and occupational therapy....
August 16th, 2017
If It’s Not a Consultation, What Is It?
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 16th, 2017
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported?
If the payer does not support these codes
If the documentation does not support ...
August 11th, 2017
Chart Auditing For Beginners
By Michelle West, CPC, CEMC, CPMA, CRC | Published August 11th, 2017
In the new year, have you found yourself in the new role of performing internal chart audits for your organization? Are you often finding yourself saying "Now What?!" First, take a deep breath and start with the basics. In this week's tip, I will review the very basic tips and ...
August 4th, 2017
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
This is a list of some of the most common Injectable unclassified drugs used with J3490
Antilirium – 1 mg/ml
Ascorbic Acid – 500 mg/ml
Ascorbic Acid – 250 mg/ml
Bacitracin, Intramuscular – 50,000 unit vials
Bacitracin, Intramuscular – 10,000 unit vials
Brevital Sodium – 500 mg/5 ml
Caffeine and Sodium Benzoate – 250 mg/ml
Capastat Sulfate – 1 ...
July 28th, 2017
Auditing Vaccines
By Paul Chandler | Published July 28th, 2017 - Last Review/Update January 31st, 2018
Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding.
July 14th, 2017
Don’t Overlook Diagnosis Codes During Coding Audits
By Betty Stump, MHA, RHIT, CPC, CCS-P, CPMA, CDIP | Published July 14th, 2017
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 ...
July 13th, 2017
Our Claims are Being Rejected
By ChiroCode | Published July 13th, 2017 - Last Review/Update February 8th, 2019
Question: Our claims are being rejected. We think it is related to our diagnosis codes. What is the reason for this?
June 30th, 2017
Focus Audit Results on the Documentation, Not the Encounter
By Scott Kraft, CPC, CPMA | Published June 30th, 2017
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 ...
June 30th, 2017
Documentation: Carrying Forward or Ineffective Use of Templates
By Shannon DeConda | Published June 30th, 2017
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 ...
June 30th, 2017
Penalties Under the False Claims Act Have Risen for the Second Time Within the Last 12 Months
By Robert Liles, JD, MBA, MS | Published June 30th, 2017
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 ...
June 30th, 2017
Auditing Neurologic Exams: Tips for Success
By Laurie Oestreich | Published June 30th, 2017
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 ...
June 30th, 2017
Getting Serious About Your Practice’s Compliance
By Jesse Overbay, JD | Published June 30th, 2017
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 ...
June 30th, 2017
Ashby’s Law of Requisite Variety; A Lesson in Preparedness
By Frank Cohen, MBA, MPA | Published June 30th, 2017
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 ...
June 30th, 2017
Consultation or Transfer of Care, What are the Differences?
By Dee MiMauro, CPC, COC, CPMA | Published June 30th, 2017
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 ...
June 30th, 2017
The Difference Between Leadership and Management
By Kelly Ogle, BSDH, MIOP, CMPM, CHOP | Published June 30th, 2017
"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 ...
June 30th, 2017
Laceration Repairs
By Michael Loss, CPC, CPMA | Published June 30th, 2017
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 ...
June 30th, 2017
Sanction Screening and Evaluating Employee Suitability: The New “Seventh Element” of Compliance
By Paul Weidenfeld, JD | Published June 30th, 2017
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 ...
June 30th, 2017
Neck: Supple
By Shannon DeConda | Published June 30th, 2017
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 ...
June 30th, 2017
Diagnosing, Documenting, and Coding for Radiculopathy
By Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP | Published June 30th, 2017
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 ...
June 30th, 2017
Outpatient Physical Therapy Changes Effective June 13th, 2017
By Shannon DeConda | Published June 30th, 2017
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 ...
June 30th, 2017
The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims
By David Glaser, JD | Published June 30th, 2017
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 ...
June 30th, 2017
Treating Diabetic Patients in Your Office?
By Shannon DeConda | Published June 30th, 2017
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 ...
June 30th, 2017
Wanna Cry?
By Ann Bachman, BS MT(ASCP), CLC(AMT) | Published June 30th, 2017 - Last Review/Update August 16th, 2017
The WannaCry (short for WannaCrypt) ransomware* attack experienced worldwide in mid-May 2017 affected some 300,000 computers running Microsoft Windows operating systems in more than 150 countries. It affected healthcare institutions, communications providers, gas stations, and banks.
The attack began on Friday, May 12, 2017, encrypting data and demanding ransom payments in ...
June 29th, 2017
Think Outside the Box When Auditing Physical Exams
By NAMAS: Betty Stump, RHIT, CPC, CCS-P, CPMA | Published June 29th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
June 29th, 2017
To Disclose or Not to Disclose… That is the Question
By Sean Weiss | Published June 29th, 2017
The biggest questions I receive these days are in regard to handling potential overpayments regarding internal or external audits is whether or not the errors constitute a self-disclosure protocol. The short answer is, avoid this process unless you have verifiable fraudulent activity to report. Section 1128J(d) of the Act created ...
June 29th, 2017
NAMAS Announced New Auditing Credential!
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published June 29th, 2017
At NAMAS, we strive to be the industry expert in auditing and compliance education. Each year, we carefully select our weekly webinar topics, annual conference sessions, and speakers to provide you with the type of training and education you need to succeed in your role. We are excited to share ...
June 29th, 2017
Focus on Clinical Documentation to Improve Coding and Audit Results
By Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP | Published June 29th, 2017
Auditors spend their day surrounded by the end product of the health care process. Those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical ...
June 29th, 2017
Prescription Drug Management: Is it a Level 3 or a Level 4?
By J. Paul Spencer, CPC, COC | Published June 29th, 2017
If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no ...
June 29th, 2017
Profit Depends on Efficiency
By NAMAS | Published June 29th, 2017
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 ...
June 23rd, 2017
Inpatient Compliance: Split-Shared Services
By Grant Huang | Published June 23rd, 2017 - Last Review/Update August 16th, 2017
In the inpatient setting, a physician can combine his or her documentation with that of a non-physician provider (N.P.P.) to support an E and M service while billing the resulting code under the physician. This is called a “split-shared” service and allows physicians to bill at 100% of the fee ...
June 16th, 2017
Auditing Incident-to Services
By Michael Miscoe, Esq. | Published June 16th, 2017 - Last Review/Update August 16th, 2017
To effectively audit incident-to services under Medicare, the auditor must first have an operational understanding of the rule. Unfortunately, this is not as easy as it sounds. Auditors must also understand that the incident-to rule is a Medicare only rule. This is one area where the maxim "if you are ...
March 24th, 2017
Are There any Alternatives for Code 97112 Neuromuscular Re-education?
By ChiroCode | Published March 24th, 2017 - Last Review/Update January 31st, 2019
Q: Are there any alternatives for code 97112 Neuromuscular Re-education? This code is counted toward both Chiropractic and Physical Therapy visits with BCBS, and we want to preserve the insurance benefits.
March 13th, 2017
Taxonomy Code Information - Dental
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Taxonomy Codes are used to define a Healthcare Provider type as well as the classification and area of specialization. These codes are reported on the ADA form and on the CMS-1500 Medical claim form. For a complete list of all classifications, visit FindACode.com
122300000X - DentistStatus: ActiveDefinition: A dentist is a person qualified by a ...
January 23rd, 2017
Why Should I Document a Differential Diagnosis?
By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP | Published January 23rd, 2017 - Last Review/Update February 8th, 2019
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.
December 30th, 2016
DOJ Announces $4.7 Billion in False Claims Act Recoveries: But What Does That Really Mean?
By Paul Weidenfeld | Published December 30th, 2016 - Last Review/Update August 17th, 2017
The Department of Justice (DOJ) recently announced that it had recovered $4.7 billion in False Claims settlements and judgments making it the "third best year" in "False Claims Act History." Trumpeted by many as a return to DOJ's record setting years, an examination of the numbers over time reveals that ...
December 19th, 2016
Benchmarks
By Wyn Staheli, Director of Research | Published December 19th, 2016
Benchmarking is simply a standard or point of reference against which things may be compared or assessed. For all businesses, it is a way of comparing your business processes to another business in the same industry to determine where shortfalls exist or improvements can be made to maintain profitability.
December 12th, 2016
60 Day Final Rule
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
December 4th, 2016
2017 CPT Updates Bring Big Changes to Physical Therapy
By Misty Tinch, RHIT, CPC, CPMA | Published December 4th, 2016 - Last Review/Update August 17th, 2017
For 2017, the new physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first major changes to the physical medicine and rehab codes in over twenty years. The new evaluation codes (97161-97168) replace the current PT and OT evaluation codes 97001 and 97003. The new ...
December 2nd, 2016
Risk Adjustment and Hierarchical Condition Category Coding and Auditing
By Michelle West, CPC, CEMC, CPMA, CRC | Published December 2nd, 2016 - Last Review/Update August 17th, 2017
Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997, which was implemented in 2003. This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions ...
November 28th, 2016
Product Wastage Documentation Requirements and Reporting: Using JW Modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ...
November 25th, 2016
PAMA
By M. Ann Bachman, BSMT (ASCP), CLC (AMT), CMPM | Published November 25th, 2016 - Last Review/Update August 17th, 2017
The Clinical Laboratory Fee Schedule (CLFS) final rule, "Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System" (CMS-16F) implements PAMA, the Protecting Access to Medicare Act of 2014. The purpose of this rule is to more closely align CLFS payments under Medicare with payments made by private payers. CMS perceives ...
November 18th, 2016
Preventive Medical Services
By Shannon DeConda | Published November 18th, 2016 - Last Review/Update August 17th, 2017
The guidelines for PMS (Preventive Medicine Services), like those of regular E&M services are gray and leave many puzzling questions to the auditor regarding what is exactly is REQUIRED according to guidelines. In this tip, I will try to address the areas of documentation and provide a relatively concise statement ...
November 4th, 2016
The “APSO” Note: Changes and Challenges with the Modern Patient Record
By J. Paul Spencer, CPC, COC | Published November 4th, 2016 - Last Review/Update August 17th, 2017
Thirty years before the first set of evaluation and management , or E&M guidelines was released, Dr. Lawrence Weed developed a format for the improvement of what was then a segmented medical record into a problem-oriented medical record for patients. This format evolved into the "SOAP" note, representing an acronym ...
November 3rd, 2016
Medical Cloning in EHRs
By McKenzie Harrison, CPMA | Published November 3rd, 2016 - Last Review/Update August 17th, 2017
When an entry in the medical record is worded similar to or exactly as previous records, or when parts of the medical record are exactly the same from patient to patient, this is called Medical Cloning. When this occurs, the documentation does not meet the requirements of medical necessity due ...
October 28th, 2016
Auditing Same Day Psychotherapy and E&M Services: The Time Trap
By Scott Kraft, CPC, CPMA | Published October 28th, 2016 - Last Review/Update August 17th, 2017
A problem-focused E/M service and the provision of psychotherapy on the same date of service are both separately payable, when medically necessary. A typical scenario is when the
provider treats the patient's diagnoses by documenting the appropriate level of history, exam and medical decision making - such as a decision to ...
October 22nd, 2016
Think Outside the Box When Auditing Physical Exams
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published October 22nd, 2016 - Last Review/Update October 24th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
October 21st, 2016
First Listed Diagnosis and Episode of Care
By Aimee Wilcox, MA, CST, CCS-P, CPMA | Published October 21st, 2016 - Last Review/Update August 17th, 2017
Since ICD-10-CM implementation, there has been some confusion and incorrect information disseminated about how the first-listed diagnosis code should be determined for outpatient physical therapy services. To clear up the confusion, the American Physical Therapy Association (APTA) recently reported they had contacted the ICD-10 Cooperating Parties (AHA, AHIMA, CMS, and ...
October 14th, 2016
Injections and Infusions
By Jessica Franzese, CPC, CPMA | Published October 14th, 2016 - Last Review/Update August 17th, 2017
Injection and infusion codes can be tricky. In this auditing tip, we'll break them down and help to make them a little easier to understand. Let's start first with the basics. Injections and infusion codes can be found in the medicine section of the CPT® book, codes 96360-96549. They are ...
October 7th, 2016
Is Your Practice in Need of a Wellness Visit?
By Valora Gurganious, MBA, CHBC | Published October 7th, 2016 - Last Review/Update August 17th, 2017
Are you finding yourself frustrated that you are working harder than ever but your practice income continues to drop? Are patients expressing greater frustration with longer wait times at your office? Is your staff morale declining and your own stress level is rising each day in the face of increasingly ...
September 30th, 2016
Medicare Condition Code 44
By Jeanette Anderson, CPC, CPMA | Published September 30th, 2016 - Last Review/Update August 17th, 2017
Medicare Condition Code 44 is used when an inpatient admission needs to be changed to outpatient status. There are some instances where a Medicare patient was admitted to the hospital with an inpatient status, but upon review it is deemed more appropriate for the entire encounter to be an outpatient ...
September 24th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2015)
By Wyn Staheli, Director of Research | Published September 24th, 2016
Medicare claims review sheds light on problem areas for behavioral health providers.
September 23rd, 2016
Documentation Rules vs. Guidelines – Is it Just Semantics, or Something More?
By Shannon DeConda | Published September 23rd, 2016 - Last Review/Update August 17th, 2017
This article was previously published in BCAdvantage Issue 11.5- September/October 2016
Most of us learned at a young age that rules are set in stone. Guidelines, on the other hand, are open to interpretation. Consider the last time you-or someone you know-was stopped by a police officer for speeding. Do you ...
September 16th, 2016
Measure Up: Wound Measurements & Debridement Auditing
By Grant Huang, CPC, CPMA | Published September 16th, 2016 - Last Review/Update August 17th, 2017
Wound care can be a tricky arena for auditors, but if there's any one element that providers tend to skimp on, it's wound measurements. Getting wound measurements right is crucial, but providers can sometimes be slapdash with documenting their measurements. Let's review what's required in terms of measurements for the ...
September 9th, 2016
Who Can It Be Knocking at Your Door? Are You Prepared?
By Sean Weiss | Published September 9th, 2016 - Last Review/Update August 17th, 2017
The truth is you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced. With that said, you can use this tip to help understand what your obligations are and how to act to ensure it is as smooth a process as ...
September 2nd, 2016
Little Things People Hate About Their Colleagues – Are You Guilty?
By Bernard Marr | Published September 2nd, 2016 - Last Review/Update August 17th, 2017
Article was republished with permission from author.
It's true that we can't choose our families, but in most cases, we also don't get to choose our work colleagues - and many of us spend more time with the people at work than we do with our blood kin! According to a ...
August 19th, 2016
Chief Complaint
By Shannon DeConda | Published August 19th, 2016 - Last Review/Update August 17th, 2017
What do you do when you come across an E&M encounter that has no chief complaint? Do you deem the encounter non-billable?
For years, I have heard it said that EVERY encounter MUST have a chief complaint, bus is that really what documentation guidelines have to say? The only guidance we ...
August 11th, 2016
When the Government Tries to Change the Rules
By Sean Weiss | Published August 11th, 2016 - Last Review/Update August 17th, 2017
We all know that the government doesn't fight fair. This is why it is so critical for healthcare professionals to understand their recourse when the government does not follow
their own guidelines. Providing audit appeal defense services to clients all over the country, we are seeing MACs and ZPICs making determinations ...
August 7th, 2016
Don’t Undervalue Patient Complexity
By Robin Sewell, CCS, CPC, CHTS-PW | Published August 7th, 2016 - Last Review/Update August 17th, 2017
Healthcare professionals can readily discern the acuity and severity of a patient's illness based on the presentation of the patient and objective data at their disposal. Although it is the responsibility of the clinician to convey the complexity of the case, it is not always easy for an auditor to ...
August 5th, 2016
History of Present Illness
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 5th, 2016 - Last Review/Update August 17th, 2017
Per Medicare's 1995 and 1997 documentation guidelines, "HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present." The History of Present Illness (HPI) is the story that explains the progress of the condition ...
August 3rd, 2016
Billing Units
By Wyn Staheli, Director of Research | Published August 3rd, 2016
Are you billing units correctly? This article outlines important considerations to ensure that claims are submitted properly.
July 29th, 2016
Modifier 22
By J. Paul Spencer, CPC, COC | Published July 29th, 2016 - Last Review/Update August 17th, 2017
Depending on a surgeon's area of expertise, documentation becomes an important tool not simply as a marker of care quality, but for the proper capture of charges and reimbursement. This past January 1st marked the 20th anniversary of CMS' adoption of Correct Coding Initiative (CCI) bundling edits, which have over ...
July 22nd, 2016
MACRA & MIPS Explained
By James Goosie | Published July 22nd, 2016 - Last Review/Update August 17th, 2017
You may have already heard that on April 16, 2015, the bipartisan legislation signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA was created to repeal the sustainable growth formula, change the way physicians are paid by going to a value- based system instead of ...
July 15th, 2016
Compliance Plans: The Truth About Templates
By Sean Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published July 15th, 2016 - Last Review/Update August 17th, 2017
This is not an article about building an effective compliance plan. It is about the most efficient and accurate way to build it and some of the nuances to be aware of when using a template to build your plan. As a compliance officer and someone that spends my days ...
July 8th, 2016
What You Need to Know About 2017 ICD-10 Updates
By Jessica Franzese, CPC, CPMA | Published July 8th, 2016 - Last Review/Update August 17th, 2017
October 2016 brought us the implementation of ICD-10-CM. The switch from ICD-9-CM to ICD-10- CM brought with it a level of uncertainty and maybe even a little panic. With a great deal of preparation and planning in place, the implementation came and went without too much trouble. Now that we've ...
July 1st, 2016
Demystifying the 7th Character in ICD-10-CM
By Aimee Wilcox, MA, CST, CCS-P, CPMA | Published July 1st, 2016 - Last Review/Update August 17th, 2017
Since implementation of ICD-10-CM on October 1, 2016, the proper application of the 7th character has caused confusion and subsequent claims denials. ICD-9-CM, 'aftercare' codes have been replaced by 7th character codes in ICD-10-CM. The 7th characters identify active treatment, healing phase, and sequale (all healed up but the patient's ...
June 28th, 2016
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
By Find-A-Code | Published June 28th, 2016
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 24th, 2016
Study the Rules Before Auditing E&M Services by Teaching Physicians
By Sara San Pedro, CPC, CEMC, CPMA | Published June 24th, 2016 - Last Review/Update August 17th, 2017
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 21st, 2016
Voluntary Overpayments
By Wyn Staheli, Director of Research | Published June 21st, 2016
When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.
June 17th, 2016
Comparative Billing Reports (CBRs): The Truth About Your Numbers
By Sean M. Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published June 17th, 2016 - Last Review/Update August 17th, 2017
More and more I am receiving calls from clients and their attorneys from around the country asking what these CBRs mean and whether they should be concerned. The answer is simple: any time a payor or one of their contracted "Bounty Hunters" sends you a letter stating you're an outlier ...
June 16th, 2016
Q&A: Will Using Lower Level Codes Reduce Our Chances of Being Audited?
By ChiroCode | Published June 16th, 2016 - Last Review/Update March 5th, 2019
Q&A: If we use low level codes on each visit (such as 98940, 99212, 99202), will our chances of being audited be less than if we billed higher level codes?
June 10th, 2016
Medical Necessity & Its Impact on E/M Services: Ensure You Always Land on the Correct Level of Service
By McKenzie Harrison, CPMA | Published June 10th, 2016 - Last Review/Update August 17th, 2017
One of the areas dating back to the first change in how providers select codes for visits is still causing problems today and at almost the same rate. The high rate of improper Evaluation and Management (E&M) levels and the failure to adequately demonstrate medical necessity (nature of presenting problem) ...
June 9th, 2016
Understanding and Using Taxonomy Codes to Maximize Reimbursement
By | Published June 9th, 2016
Taxonomy codes are used by insurers as indicators of legal scope of practice. Scope of practice is key to getting reimbursed under the Affordable Care Act or ObamaCare. However, Most providers will only choose one taxonomy code to describe their training. This limits their scope of practice. To maximize scope ...
June 7th, 2016
Q/A: Do you Have any Recommendations for Audit Prevention?
By ChiroCode | Published June 7th, 2016 - Last Review/Update March 5th, 2019
Q: Do you have any recommendations for audit prevention?
June 3rd, 2016
Electronic Medical Records: Is Your EMR Making You Look Like a Bad Doctor?
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published June 3rd, 2016 - Last Review/Update August 17th, 2017
"As of the end of 2015, 56 percent of all U.S. office-based physicians (MD/DO) have demonstrated meaningful use of certified health IT in the Centers for Medicare and Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Programs." [1]
More than half of the physicians in practice in the United States currently ...
May 27th, 2016
Documentation Criteria: Medicare Physicals
By Jeanette Anderson, CPC, CPMA | Published May 27th, 2016 - Last Review/Update August 16th, 2017
When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already ...
May 20th, 2016
Pass-Through Billing and Shared Labs
By Ann Bachman, CLC (AMT), MT (ASCP) | Published May 20th, 2016 - Last Review/Update August 16th, 2017
Pass-through billing has mostly passed on.
Pass-through billing is an arrangement between a physician practice and a reference laboratory that allows the physician practice to submit specimens to the reference lab for testing, pay that laboratory directly, and then bill the payer (insurance or patient) for the test, usually at a ...
May 13th, 2016
Using the Right Diagnosis
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published May 13th, 2016 - Last Review/Update August 16th, 2017
One of the hardest parts when reviewing a medical record for coding or auditing is the determination of what conditions were addressed. Any condition that is taking into account or affects patient care, treatment or management should be documented and ultimately coded. However, the documentation still needs to support that ...
May 6th, 2016
This Week’s Auditing & Compliance Tip Comes from a Recent NAMAS Q&A
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published May 6th, 2016 - Last Review/Update August 16th, 2017
In the setting of incident-to billing, if an established patient presents with a known history of benign lesions including actinic keratosis previously treated by cryo, would the presence of new skin lesions be considered a 'new problem' that requires physician involvement OR is the previous history and treatment plan sufficient ...
April 29th, 2016
Auditing Exams: Detailed Exams
By Grant Huang, CPC, CPMA | Published April 29th, 2016 - Last Review/Update August 16th, 2017
You might think the physical exam portion of an E/M note is one of the simplest areas to audit. After all, you don't have to worry about all the possible words a physician might use in the history that you'll need to qualify as elements of the history of present ...
April 8th, 2016
Amending the Medical Record
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published April 8th, 2016 - Last Review/Update August 16th, 2017
A medical record is a legal document and therefore there is a right way to modify a record and certainly a wrong way as well. All modifications and addendums must follow the guidelines whether it is the provider or ancillary staff that are modifying their own entries. Addendums may be ...
April 5th, 2016
Voluntary Disclosure - Look Before You Leap
By ChiroCode | Published April 5th, 2016
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
April 1st, 2016
Who Audits the Auditor?
By Michelle West, CPC, CEMC, CPMA | Published April 1st, 2016 - Last Review/Update August 16th, 2017
Does your facility have a policy in place which addresses quality assurance? It is vital to ensure that regulatory and internal compliance plan policies are being followed by those who are responsible for internal chart audits.
Even before you review internal audits, here are some tips to ensure their quality:
Is your ...
March 25th, 2016
Auditing Smoking Cessation Services
By John Burns, CPC, CPC-I, CEMC, CPMA | Published March 25th, 2016 - Last Review/Update August 16th, 2017
Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) ...
March 18th, 2016
TCM, CCM, and Clinical Staff Members
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published March 18th, 2016 - Last Review/Update August 16th, 2017
When auditing Transitional Care Management (TCM) and Chronic Care Management (CCM) services, you may come into a situation where services are performed by clinical staff members. What constitute as a clinical staff member, and are they allowed to perform such services? What if they are not licensed?
CMS is vague about ...
March 11th, 2016
The Importance of Verifying Regulatory Guidance
By Jessica Franzese, CPC, CPMA | Published March 11th, 2016 - Last Review/Update August 16th, 2017
In the world of medical documentation, things are constantly changing. As medical coding and auditing professionals, we know that CPT and ICD-10 CM codes change annually. We are quick to keep up with these changes, ensuring such things as software updates and the purchase of new manuals. But are we ...
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
March 4th, 2016
Guidance for Modifier 24 Usage
By Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016 - Last Review/Update August 16th, 2017
Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record request, so we must be confident when ...
February 26th, 2016
Auditing for Cerumen Removal Codes 69209, 69210
By Scott Kraft | Published February 26th, 2016 - Last Review/Update August 16th, 2017
2016 brings changes to how physician practices bill for the removal of impacted cerumen, including a new CPT code. The rules that apply to the two cerumen removal codes now available for use mean that auditors will need to scrutinize the documentation closely in order to ensure codes are being ...
February 25th, 2016
Narrative Support suggestions for Dental
By Christine Taxin | Published February 25th, 2016
Suggestions for narrative support for use in Box 19 CMS-1500 and Box 35 of the ADA Dental Claim Form
February 24th, 2016
Employee Exclusions Screenings Must be High Priority
By Wyn Staheli | Published February 24th, 2016
Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. This article has important information for organization to ensure compliance.
February 19th, 2016
Is Your Patient PHI Fully Protected?
By Kelly Ogle, BSDH, MIOP, CHOP, CMPM | Published February 19th, 2016 - Last Review/Update August 16th, 2017
As you probably know, HIPAA stands for the Health Insurance Portability and Accountability Act. This means that as healthcare professionals, we must hold ourselves accountable when handling patient information. This goes beyond having conversations with unauthorized people about what we see or hear in the office. Unlike OSHA, patients, employees, ...
February 15th, 2016
Unified Program Integrity Contractors (UPIC)
By InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
February 12th, 2016
Patient Status: Hospital Inpatient vs. Observation
By Jeanette Anderson, CPC, CPMA | Published February 12th, 2016 - Last Review/Update August 16th, 2017
As an auditor, we must ensure that the documentation supports the selected use of codes for reimbursement. When auditing hospital encounters, the patient status serves as the basis for the code selection and therefore must be clearly documented. This ensures that the hospital is able to collect appropriate reimbursement.
During an ...
February 5th, 2016
The Assurance of Quality Assurance
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published February 5th, 2016 - Last Review/Update August 16th, 2017
Does your organization have a Quality Assurance (QA) plan in place? Does it contain policies for escalations or what to do when certain issues arise? Even organizations with the most experienced of auditors on staff can find extreme value in creating - and following - an effective quality assurance plan.
Many ...
February 1st, 2016
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
January 29th, 2016
Opioid Abuse and House It Will Impact Physicians
By James Goosie, MBA | Published January 29th, 2016 - Last Review/Update August 16th, 2017
One of the largest issues that the healthcare industry is facing, which no one wants to really deal with, is the addiction to opioids in the United States. In 2014, an estimated 2 million people in the United States were addicted to opioids. In 2013, the United States became the ...
January 22nd, 2016
Think Outside the Box When Auditing Physical Exams
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published January 22nd, 2016 - Last Review/Update August 16th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
January 6th, 2016
CMS-1500 form revised to fit more diagnosis codes, less patient demographic information
By Codapedia | Published January 6th, 2016
CMS-1500 form revised to fit more diagnosis codes, less patient demographic informationIt doesn’t get used nearly as much as it used to, but there is a new CMS-1500 claim form that has been revised slightly to fit more diagnosis codes and to facilitate the transition to...
January 6th, 2016
6 ways to stop filing duplicate Medicare claims - Duplicates could expose your practice to fraud investigation
By | Published January 6th, 2016
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
December 21st, 2015
ROS Checklist
By | Published December 21st, 2015
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ? Lumps ? Itching ? Dryness ? Color changes ? Hair and nail changes ----------------------------------------------------------------------------------- -Head- ? Headache ? Head...
December 21st, 2015
What Does It Mean To Scrub An Insurance Claim?
By Codapedia | Published December 21st, 2015
During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the lifeblood for...
December 11th, 2015
Charge capture: Paper and Electronic Encounter Forms
By Codapedia | Published December 11th, 2015
Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and diagnosis...
December 3rd, 2015
Hospital Observation Services
By Codapedia | Published December 3rd, 2015
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary. This period of time...
December 3rd, 2015
Why Get Into Medical Billing?
By Codapedia | Published December 3rd, 2015
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over...
December 3rd, 2015
Interval History
By Codapedia | Published December 3rd, 2015
In the CPT® book, some E/M codes are described as requiring an "expanded problem focused history" or a "detailed history." Others require "an expanded problem focused interval" history or a "detailed interval history." What's the difference? Past medical, family and social history. These three are not...
December 2nd, 2015
99212--established patient visit - Sample audited notes
By | Published December 2nd, 2015
Established patient visits all require 2 out of 3 of history, exam, medical decision making 99212: History required is problem focused: 1-3 HPI elements Exam required is problem focused: 1 body area/organ system examined from the 1995 exam, or one bullet from the multi-specialty exam...
December 2nd, 2015
Chief Complaint - Rules related to the Chief Complaint in the D.G.
By | Published December 2nd, 2015
The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the...
December 2nd, 2015
Past medical, family and social history - Documenting and auditing the history section of an E/M service
By | Published December 2nd, 2015
When an Evaluation and Management service requires past medical, family and social history, (or one or two of those) here is what needs to be documented, and the rules around using one that is previously documented. Past medical history includes the patient's chronic illnesses, previous...
December 2nd, 2015
History of the present illness - HPI Rules from the Documentation Guidelines
By | Published December 2nd, 2015
Here are the elements of the HPI: Location: Where do the patient's symptoms occur? In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur. Head, shoulders, knees...
December 2nd, 2015
It’s a home health crackdown, but your phone’s going to ring
By Codapedia | Published December 2nd, 2015
Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care. Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to certify home health care by...
December 2nd, 2015
Yet another new auditor looking at Part B claims
By Codapedia | Published December 2nd, 2015
Recovery Audit Contractors (RACs) may be about to take a break while CMS awards new contracts, but don’t rest on your laurels. CMS has handed out yet another auditor contract for a single auditor, known as a Supplemental Medical Review Contractor (SMRC) to do nationwide claims...
December 2nd, 2015
CMS puts the brakes on RAC audits for now, and implements changes for when they return
By Codapedia | Published December 2nd, 2015
Good news for physician practices that don’t like getting demand letters and record requests from Recovery Audit Contractors (RACs). All those requests will stop by Feb. 28 on orders from CMS. RACs will be back once CMS awards new RAC contracts, but those awards may...
December 2nd, 2015
CMS looking for ways to boot providers who don’t correct repeated billing problems
By Codapedia | Published December 2nd, 2015
Providers with a history of making the same mistakes over and over again may find themselves on the outside of the Medicare program looking in, if CMS has its way. The agency has formalized a policy to use existing regulations to identify these providers and be...
December 2nd, 2015
CMS clarifies the ways physician practices can respond to additional documentation requests
By | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
December 2nd, 2015
Will the RACs audit E/M services?
By Codapedia | Published December 2nd, 2015
This is the $10,000 question: will the RAC auditors, now in place throughout the country, look at E/M services? Here is what CMS says in its FAQ on the topic: From their website: Will the Recovery Audit Contractors (RAC) review evaluation and management (E&M) services on...
December 2nd, 2015
Do headings matter in an E/M note?
By Codapedia | Published December 2nd, 2015
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past...
November 24th, 2015
You do not need to change or rewrite your original orders
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
November 19th, 2015
Review of Systems - ROS Rules for Auditing
By | Published November 19th, 2015
Sometimes one symptom can be used in more than one system. For example, dizziness. Although we typically think of this as a neurological symptom, sometimes cardiologists ask about dizziness and relate it to the cardiovascular system.
In the citations section of this entry, there are references for symptoms ...
October 5th, 2015
Reporting Laterality Still Requires Modifiers
By Wyn Staheli, Director of Research | Published October 5th, 2015
One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added).
Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ...
August 19th, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
August 19th, 2015
What to Do When a Payer Audits You
By | Published August 19th, 2015 - Last Review/Update January 27th, 2017
When a payer audits you the first thing to do is respond to the audit. Do not ignore it; it won’t go away. In the initial stage of the audit, they will probably ask you to send them your notes on approximately 5-10 patients. Either have a health care attorney or yourself send ...
August 10th, 2015
Audit Fighting Tactics
By Tom Necela, DC, CPC, CPMA, CCP-P | Published August 10th, 2015 - Last Review/Update January 27th, 2017
Four Tactics or tips to help you fight back when you are audited or have your claims reviewed. They are effective and easy to use.
August 10th, 2015
Alphabet Soup for Waste and Fraud Inspectors
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
The following are some of the acronyms you would need to know when communicating with auditors:
National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.
Medically Unlikely Edits (MUE): Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.
Office of the ...
July 20th, 2015
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
The Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to Medicare electronically unless certain exceptions are met. In addition, the Health Insurance ...
July 20th, 2015
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
By Find-A-Code | Published July 20th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject ...
July 10th, 2015
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory ...
July 10th, 2015
Carrier Claims Processing - Jurisdiction of Laboratory Claims (Rev. 3071, 12-22-14)
By Jared Staheli | Published July 10th, 2015
Jurisdiction of payment requests for laboratory services furnished by an independent laboratory, except where indicated in §50.5.1 and §50.5.2, lies with the B MAC serving the area in which the laboratory test is performed. Jurisdiction is not affected by whether or not the independent laboratory uses a central billing office ...
July 10th, 2015
Carrier Claims Processing - Examples of Reference Laboratory Jurisdiction Rules (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
EXAMPLE 1:
Scenario 1:
An independent laboratory located in Oregon performs laboratory services for physicians whose offices are located in several neighboring States. A physician from Nevada sends specimens to the Oregon laboratory.
Jurisdiction:
The carrier in Oregon has jurisdiction.
EXAMPLE 2:
Scenario 2:
American Laboratories, Inc., is an independent laboratory company with branch ...
July 10th, 2015
Claims Processing Requirements for Panel and Profile Tests (Rev. 372, 04-04-05)
By Jared Staheli | Published July 10th, 2015
All test codes should be processed and stored in history as they are submitted. That is, if tests are submitted as individual CPT codes together and paid as a panel (see §90), the claim history data will reflect the individual codes and the panel used in pricing. All tests must ...
July 9th, 2015
Claims Processing Instructions for the Designated Carrier (Rev. 866, 07-03-06) - Competitive Acquisition Program
By Jared Staheli | Published July 9th, 2015
The designated carrier shall follow normal procedures to enroll the Drug Vendors as provider specialty type, 95, Competitive Acquisition Program (CAP) for Part B Drug Vendors.
A separate 4 position, alpha-numeric vendor identification number (VIN) shall be assigned to be used in the prescription number and a master list of which ...
July 9th, 2015
Claims Processing for Separately Billable Tests for ESRD Beneficiaries (Rev. 1655, 02-02-09)
By Jared Staheli | Published July 9th, 2015
Clinical laboratory tests can be performed individually or in predetermined groups on automated profile equipment. If a test profile is performed see §40.6.1. If a clinical laboratory test is performed individually, see §40.6.2.1. However the tests are performed in the laboratory setting, the services must be billed individually, and must ...
July 9th, 2015
Carrier Claims Processing - Referring Laboratories (Rev. 85, 02-06-04)
By Jared Staheli | Published July 9th, 2015
Medicare recognizes that specimens drawn or collected by one laboratory are sometimes referred to another laboratory for testing. Payment for a Medicare-covered, referred laboratory service may be made under the rules established in Chapter 15 §40.1.
The rules specified Chapter 15 §40.1 do not apply to services performed in a physician ...
July 9th, 2015
Carrier Claims Processing - Physicians (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
If a physician or medical group furnishes laboratory tests in an office setting and it is appropriate for them to be performed in the physician’s office, no further development of the source of the laboratory tests is required.
If a claim or physician’s bill raises a question as to the source ...
July 9th, 2015
Carrier Claims Processing - Assignment Required (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Carriers must:
• Pay for clinical laboratory services provided in the physician’s office only on an assignment basis.
• Treat as assigned any claims for clinical laboratory services provided in the physician’s office even if the claimant submits the claim on a non-assigned basis or if the assignment option is not designated.
• ...
July 9th, 2015
Carrier Claims Processing - Hospital-Leased Laboratories (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Carriers process claims from hospital laboratories that are leased by physicians and independent laboratories.
Before processing claims for services furnished by a hospital laboratory department operated on a lease or concession basis by a pathologist or by a nonphysician specialist such as a biochemist (with a visiting pathologist or outside independent ...
July 9th, 2015
Carrier Claims Processing - Hospital Laboratory Services Furnished to Nonhospital Patients (Rev. 3014, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
When a hospital laboratory performs a laboratory service for a non-hospital patient, (i.e., for neither an inpatient nor an outpatient), the hospital bills its A/B MAC (A) on the ASC X12 837 institutional claim format or on the hard copy Form CMS-1450. If an A/B MAC (B) receives such claims, ...
July 9th, 2015
Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
The national coverage determination (NCD) titled, “The Use of ESAs in Cancer and Other Neoplastic Conditions” lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself. The full NCD can be ...
July 9th, 2015
Claims Processing Rules for Hospital Outpatient Billing and Payment - Drugs, Biologicals, and Radiopharmaceuticals (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals
Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing ...
July 8th, 2015
Claims Processing Requirements - General (Rev. 3085, Implementation: Upon Implementation of ICD- 10)
By Jared Staheli | Published July 8th, 2015
A/B MACs (B) are billed with the ASC X12 837 professional claim format or, if approved, with the paper form CMS-1500. A/B MACs (A) are billed with the ASC X12 837 institutional claim format or, if approved, with the paper Form CMS-1450.
See Chapters 24, 25 and 26 for detailed claims ...
July 8th, 2015
Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
The following chart shows which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC.
Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 ...
July 6th, 2015
Claims Adjustment Reason Codes for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
Contractors shall use the appropriate Claim Adjustment Reason code, such as 149 (Lifetime benefit maximum has been reached for this service/benefit category) when denying additional claims for an IPPE and/or a screening EKG.
...
July 6th, 2015
Correct Place of Service (POS) Codes for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay for IBT CVD, G0446 only when services are provided at the following POS:
11- Physician’s Office
22-Outpatient Hospital
49- Independent Clinic
72-Rural Health Clinic
Claims not submitted with one of the POS codes above will be denied.
The following messages shall be used when Medicare contractors deny professional claims for incorrect POS:
Claim Adjustment ...
July 5th, 2015
Edits for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
A. Common Working File Edits
Effective January 1, 2002, CWF edits glaucoma screening claims for frequency and valid HCPCS codes for dates of service January 1, 2002, and later.
B. Claims Edits
Nationwide claims processing edits for pre or post payment review of claim(s) for glaucoma screening are not required at this ...
June 29th, 2015
HIPAA Standards for Claims
By Find-A-Code | Published June 29th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The standards adopted under HIPAA include both a transaction standard and an implementation guide. The following are the claims transactions and the implementation ...
June 25th, 2015
FI – Telehealth Originating Site Facility Fee – Medicare Part B – Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if this is the only service received. ...
June 25th, 2015
Audit of IHS Cost Reports (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS hospitals that convert to CAH status are subject to audit by the FI. CMS’ audit policy can be found in Chapter 8, Contractor Procedures for Provider Audit, of Pub. 100- 06, Medicare Financial Management Manual.
The CAHs are reimbursed under the Medicare Principles of Reasonable Costs. These principles are ...
June 25th, 2015
Claims Submitted to Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Medicare does not require that the influenza virus vaccine be administered under a physician’s order or supervision. Effective for claims with dates of service on or after July 1, 2000, Medicare does not require that pneumococcal vaccinations be administered under a physician’s order or supervision. Medicare still requires that the ...
June 25th, 2015
Simplified Roster Claims for Mass Immunizers (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass pneumococcal and influenza virus vaccination programs offered by PHCs and other individuals and entities that give the vaccine to a group of beneficiaries, e.g. at PHCs, shopping malls, grocery stores, senior citizen homes, and health ...
June 25th, 2015
Roster Claims Submitted to AB MACs for Mass Immunization (Rev. 3159, 02-02-15)
By Jared Staheli | Published June 25th, 2015
If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted Form CMS-1500 that contains standardized information about the entity and the benefit. Key information from the beneficiary roster list and the abbreviated Form CMS-1500 is used to process pneumococcal and influenza virus ...
June 25th, 2015
Claims Submitted to FIs/AB MACs for Mass Immunizations of Influenza Virus and Pneumococcal Vaccinations (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Some potential "mass immunizers," such as hospital outpatient departments and HHAs, have expressed concern about the complexity of billing for the influenza virus vaccine and its administration. Consequently, to increase the number of beneficiaries who obtain needed preventive immunizations, simplified (roster) billing procedures are available to mass immunizers. The simplified ...
June 25th, 2015
Electronic Roster Claims (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
As for all other Medicare-covered services, FIs/AB MACs pay electronic claims more quickly than paper claims. For payment floor purposes, roster bills are paper bills and may not be paid as quickly as EMC. (See chapter 1.) If available, FIs/AB MACs must offer free, or at-cost, electronic billing software and ...
June 25th, 2015
CWF Edits on Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
In order to prevent duplicate payment by the same carrier/AB MAC, CWF will edit by line item on the carrier/AB MAC number, the HIC number, the date of service, the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688; the ...
June 25th, 2015
CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
When CWF receives a claim from the carrier/AB MAC, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
CWF will edit on the beneficiary HIC number; the date of service; the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, ...
June 25th, 2015
Carrier - Claims Processing Requirements for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
1. Claims will be submitted by IHS physicians and practitioners using either the American National Standards Institute Accredited Standards Committee (ANSI ASC) 837P or Form CMS-1500.
2. The designated carrier shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non-physician practitioners.
3. The ...
June 25th, 2015
Carrier – Ambulance Services - Claims Processing (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulances provided by an IHS ambulance supplier are paid based upon Chapter 15 of Pub. 100-04, Medicare Claims Processing Manual. Suppliers must report an origin and destination code for each ambulance service billed.
Modifier Reporting –
Origin and destination modifiers used for ambulance services are created by combining two alpha ...
June 25th, 2015
Carrier - Clinical Laboratory Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Some clinical laboratory procedures or tests require FDA approval before coverage is provided. Laboratory services furnished by a freestanding facility are covered under Medicare Part B if the laboratory is an approved independent clinical laboratory. However, as is the case of all diagnostic services, in order to be covered these ...
June 25th, 2015
Carrier – MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If the RD providing the services is an employee of an independent or free standing clinic and the services are provided in the clinic, the services are billed to the designated carrier.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on the Healthcare ...
June 25th, 2015
Carrier Claims Processing and Payment Policy for ASC Claims for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Effective for services on or after January 1, 2008, the designated IHS carrier shall accept and pay for claims submitted by IHS and tribal hospitals that elect to enroll as ASC facilities. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 14, for information on ASC claims processing. See Pub. 100-02, ...
June 25th, 2015
General Claims Processing Rules for DMEPOS for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The DME MACs may only be billed for surgical dressings, splints, casts and for prosthetics and orthotics by IHS suppliers, not by IHS providers. The Region D DME MAC shall accept all DMEPOS claims submitted by IHS suppliers and shall forward electronic media claims to the appropriate DME MAC for ...
June 25th, 2015
A/B MAC (A) Payment Policy and Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
Bills are submitted to the A/B MAC (A) by IHS providers (including CAHs) using the ASC-X12 837 institutional claim format. In exceptional circumstances, a hardcopy Form CMS-1450 may be accepted by the designated A/B MAC (A).
The IHS providers are identified by Provider Type 08 in the Provider Specific File in ...
June 25th, 2015
A/B MAC (A) - Inpatient Acute Care - Medicare Part A - Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on type of bill (TOB) 11X (hospital inpatient). Inpatient services are billed from admission through discharge. Interim billing is not allowed.
See Chapter 1, §50.2 of Pub. 100-04, Medicare Claims Processing Manual, for more information ...
June 25th, 2015
FI - Inpatient Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but ...
June 25th, 2015
Swing-bed – Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Revenue code 0022 (special charges) and the Health Insurance Prospective Payment System (HIPPS) codes are reported on the bill along with the accommodation revenue codes. Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing bed). Medicare swing-bed bill processing instructions ...
June 25th, 2015
FI - Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).
Regardless of the number of times a patient is seen in a given day at ...
June 25th, 2015
FI - ASC - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Charges are reported under revenue code 0360 (operating room services) or 0490 (ambulatory surgical care) on TOB 83X (ambulatory surgical center). ASC surgeries are identified with CPT codes 10000-69979 only. One bill is required for all services provided on the day a surgical procedure is performed.
*Exception: Revenue code 0276 (intraocular ...
June 25th, 2015
FI - CAH Inpatient - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X (hospital inpatient). Inpatient services are billed from admission through discharge.
The MSN is suppressed.
...
June 25th, 2015
FI - CAH Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). The MSN is suppressed.
See §§100.10 and 100.11 of this chapter, for more information on the payment of ...
June 25th, 2015
FI - CAH Swing-bed - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing-bed). Technical criteria for swing-bed admissions apply (i.e., 3 day qualifying hospital stay, 30 day transfer requirements, etc.) but CAH swing-bed providers are not required to report revenue code 0022 or HIPPS ...
June 25th, 2015
FI - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAH swing-bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swing-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is ...
June 25th, 2015
FI - CAH Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine, and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 85X (CAH).
Non-patient lab specimens are billed on TOB 14X (hospital other).
The MSN is suppressed.
See Chapter18, §10 of Pub. ...
June 25th, 2015
FI - Vaccines and Vaccine Administration - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
These vaccines are reported on TOB 12X, 13X, 83X, or 85X along with the appropriate revenue codes and HCPCS codes as found in billing instructions in Chapter 18, §10.2 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if vaccine and its administration are the only service ...
June 25th, 2015
FI - Physical Therapy, Occupational Therapy, SpeechLanguage Pathology and Diagnostic Audiology Services - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Therapy services and diagnostic audiology services are reported on TOB 12X, 13X, 83X or 85X using the appropriate revenue code and HCPCS codes.
No clinic visit shall be billed if a therapy service or a diagnostic audiology service is the only service received. These services may be billed with or without ...
June 25th, 2015
FI - CAH Ambulance Services - Medicare Part B -Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulance services originating out of an IHS CAH with a hospitalbased ambulance service are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 85X. IHS CAHs that meet the 35 mile rule for cost based payment shall ...
June 25th, 2015
FI - Other Screening and Preventive Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The screening and preventive services listed in §100.13 of this chapter are reported on TOB 12X, 13X, or 85X with revenue code 0510 (clinic visit).
Services for screening pap smears are only payable by the FI when billed with a pelvic exam. Prostate cancer screening, cardiovascular screening blood tests and screening ...
June 25th, 2015
FI - MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The MNT services provided under the auspices of the hospital are reported to the designated FI under revenue code 0510 (clinic visit). The current MNT HCPCS codes are required for the both the assessment and reassessment. The MSN is suppressed.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims ...
June 18th, 2015
DME MACs Only - Appeals of Duplicate Claims (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) must afford appeal rights for the initial determination of an item or service only, unless the supplier is appealing whether or not the denied item is actually a duplicate. If a claim is denied as a duplicate, the DME MACs must ...
June 15th, 2015
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
February 26th, 2015
Levels of Supervision Required by Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
February 15th, 2015
CMS Opt-Out Regulations and Guidelines
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
February 9th, 2015
Encryption
By Wyn Staheli, Director of Research | Published February 9th, 2015 - Last Review/Update June 9th, 2016
How secure is your computer? Do you have a password on your computer? Do you have the automatic log offs turned on? Is your computer encrypted? Are your off-site storage files encrypted?
This document is designed to give some basic information about making your office a little more secure. It is not ...
January 9th, 2015
How Important is Your Fee Schedule?
By | Published January 9th, 2015 - Last Review/Update June 13th, 2016
Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:
• Prompt an audit or some level of claims review
• Cause claims delays
• Increase provider liability in case of an audit or investigation
• Potentially lead to being paid less than the actual value of ...
November 21st, 2014
Risk Adjustment, What is it?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Risk adjustments are used to compare Actual and Expected Mortality Rates using Risk Adjustments calculated by patient risk score.
BC Risk Adjustment — Risk Adjustment 101
WA Regence Administrative Manual
Risk adjustment is part of the Regence Medicare Program Management for Medicare Advantage plans. Commercial risk adjustment is a requirement of the U.S. Department ...
November 19th, 2014
Understanding ZPIC
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
November 19th, 2014
Understanding RAC
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
November 17th, 2014
Conducting a Gap Analysis for Your Documentation & Billing Systems
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 17th, 2014 - Last Review/Update January 30th, 2017
What is a Gap Analysis?
A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. This ...
October 20th, 2014
PPO Plans
By | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Are PPOs are affecting the value of your practice?
Did you know that taking a 20% PPO write-off on a $200 procedure with a 60% overhead cuts practice profits in half?
By participating in PPO plans, you agree to take a certain discount on fees; however, your fixed overhead costs remain the same ...
October 16th, 2014
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each new year. For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to ensure compliance ...
October 16th, 2014
The Role of Statistical Analysis in Fighting Fraud
By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017
It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.
September 25th, 2014
Healthcare Fraud Investigations in FY 2013
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 ...
September 9th, 2014
Compliance Specialists
By | Published September 9th, 2014
Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...
July 31st, 2014
Fill In Doctor: Locum Tenens
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ...
September 24th, 2013
Federal Health Care Fraud Summary 2012
By | Published September 24th, 2013 - Last Review/Update January 27th, 2017
Be aware of the possible monetary results and enforcement actions imposed for fraud. This is the annual report of the Department of Justice Health Care Fraud and Abuse Control Program for FY 2012
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