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Coding for a Performance of an X-ray Service vs. Counting the Work as a Part of MDM

by  Stephanie Allard, CPC CEMA RHIT

When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was...

Medicare Auditors Caught Double-Dipping

by  Edward Roche, PhD JD

Overlapping extrapolations require providers to pay twice. Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount...

Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?

Are NCCI Edits and Modifiers Just for Medicare?

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

CMS Temporarily Suspends Contract-Level RADV Audits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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.

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

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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: ...

Denials due to MUE Usage - This May be Why!

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Helping Others Understand How to Apply Incident to Guidelines

by  NAMAS

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 ...

A United Approach

by  NAMAS

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 ...

What Medical Necessity Tools Does Find-A-Code Offer?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

Q/A: I’m Being Audited? Is There a Documentation Template I can use?

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

Let's Talk High Risk E/M Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

What is Medical Necessity and How Does Documentation Support It?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

Prepayment Review Battle Plan

by  Wyn Staheli, Director of Content - innoviHealth

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. ...

The Impact of Medical Necessity on High Level E/M Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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. ...

Understanding NCCI Edits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

Coding Medicare Initial Preventive Physical Exams (IPPE)

by  Aubrie Rowley

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 ...

Clinical Staff vs. Healthcare Professional

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

How to Report Co-Surgeons Using Modifier 62

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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 ...

Wolters Kluwer Drug Pricing

by  Find-A-Code™

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...
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Select the title to see a summary and a link to the full webinar information.  some webinars require a subscription to view.

Medicare Audit, Do-it-yourself 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Evaluation and Management Coding and Auditing 

by  Find-A-Code™

Are you responsible for selecting or reviewing Evaluation and Management service levels? Do you wonder how well you know the rules and how to apply them? Join Aimee in this webinar to review and then applly the rules of E/M coding. She will also do a live demonstration of the new Find-A-Code E/M Calculator Tool to assess the level of E/M service for two office visits, one new (99201-99205) and the other established (99212-99215).

How to Check NCCI Edits Using FindACode 

by  Find-A-Code™

How to Check NCCI Edits Using FindACode

ICD-10-CM Updates for the Auditor, a NAMAS webinar 

by  Find-A-Code™

ICD-10-CM Updates for the Auditor, a NAMAS webinar

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