"Practice Management" & "OIG" Articles


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How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —

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Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.

Cross-A-Code Instructions in Find-A-Code

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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.

OIG – Fraud and Abuse Study with COVID-19 Testing

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According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...

My Location and CBSA is Missing!

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We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to ...

Coding with PCS When There is No Code

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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 ...

OIG Report Highlights Need to Understand Guidelines

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A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

New ABN Form is Here

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The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.

Understanding UCR Inpatient Fees used on DRGs

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Newest Launch - We Now Have Outpatient Facility Pricing!

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Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...

Getting Your Practice Back on Track

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As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.

Now That is Fraud! Genetic Testing "Public alert"

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Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

CMS Temporarily Suspends Contract-Level RADV Audits

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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.

Financial Impact of CARES Act on Healthcare Providers

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The recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act has several provisions to ease the financial burden being faced by healthcare providers who have been impacted by the effect of the coronavirus. Learn more about how the Provider Relief Fund and the Accelerated and Advance Payment Program work.

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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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: ...

Why is HIPAA So Important?

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Why is HIPAA So Important? Some may think that what they do to protect patient information may be a bit extreme. Others in specialty medical fields and research understand its importance a little more. Most of that importance lies in the information being protected. Every patient has a unique set of ...

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...

The OIG Work Plan: What Is It and Why Should I Care?

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The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...

The Role of Chiropractic in Value Based Payment Systems

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Chiropractic care can play a valuable role in overall patient health. It is important to realize that chiropractors can effectively participate in Medicare's new value based payment systems. Read about one organization who has made this transition.

Are These Problems Hurting Your Practice?

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There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.

Q/A: Do I Really Need to Have an Interpreter?

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Question: I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true? Answer:  Yes! There are both state and federal laws that need to be considered. The applicable federal laws are: Title VI of the Civil Rights Act of 1964,  Americans with Disabilities ...

Small Breaches Can Be Subject to Large Penalties

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Small Breaches Can Be Subject to Large Penalties    We may have heard about the large fines issued by the Office for Civil Rights (OCR) against big organizations like Anthem or the University of Texas MD Anderson Cancer Center. These organizations have been in the news due to privacy breaches that constituted violations ...

An Update on the DHS OIG's Effort to Combat Fraud & Abuse

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An Update on the DHS OIG's Effort to Combat Fraud & Abuse Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...

Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?

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Question  We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate ...

Prioritize Your Patient's Financial Experience

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For many years, the ChiroCode DeskBook has emphasized the need for providers to firmly establish the patient’s financial responsibility through clear communication. We even created a “Patient Financial Responsibility Acknowledgment Form” to help providers with this process. Lately, the lack of pricing transparency has been in the news and even ...

OIG Announces New Review For Medicare Part B Payments for Podiatry and Ancillary Services

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Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020.  The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.   Part of the ...

Auditing Chiropractic Services

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Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.

Watch out for People-Related ‘Gotchas’

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In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...

Understanding NCCI Edits

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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 ...

Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?

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It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?

Clinical Staff vs. Healthcare Professional

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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 ...

Attestations Teaching Physicians vs Split Shared Visits

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Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...

Are You Protecting Your Dental Practice From Fraud?

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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 ...


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