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Auditing Information

Audits are playing an ever-increasing role in the healthcare industry. We have created a topic page with the most general tools and resources used by auditors.  Understanding where to go to find the rules and guidelines have been simplified and accessed all in one place. 

This topic page includes helpful information on audits. In addition Find-A-Code offers a variety of tools to assist with audits. Our experts have gathered a variety of auditing information for you to do your own chart reviews.

Additional Resources

Hospital Resources

Hospital articles and resources

Guidelines and Manuals

Additional guidelines and manual resources

Facilities Articles and Resources

Information on ASC's and APC's

Medicare Resources

Medicare articles and resources by state

Find-A-Code Tools

Map-A-Code™ Code to Status

Map CPT, HCPCS, ICD-9 and ICD-10 codes to their status (ACTIVE, DELETED, etc).

HCC Risk Calculator

Get HCC risk scores with the calculator tool

Click-A-Dex

Enhanced code index searching

E/M Calculator

Use this tool to calculate an E/M (Evaluation & Management) CPT code based on components or time

NCCI Edits Validator NON-Facility

Check NCCI Edits and avoid denials

NCCI Edits Validator Facility

Check NCCI Edits and avoid denials (Facility codes)

ASC Excluded Surgical Procedures

The following procedures are not covered in an ASC setting

Inpatient Only Codes

CPT/HCPCS Inpatient Only Codes

Medical Lab Tests Search

Best tests for diseases (CLD rankings), test info, billing codes, etc.

Miscellaneous Resources

Medicare Fee for Service Recovery Audit Program

Stay in the know on proposed and approved topics that RAC's are able to review

Provider Self-Audit with Validation and Extrapolation (PSAVE) Pilot Program

Provider checklist and opt out form

E/M Documentation Auditor’s Instructions

Novitas Solutions documentation worksheet

Attorneys and Counselors at Law - Defending Providers

We Defend Healthcare Providers Nationwide in Audits & Investigations

NAMAS

NAMAS

National Alliance of Medical Auditing Specialists

NAMAS Self Assessment

Identify the medical audit training you need!

OIG

OIG Compliance Resource Portal

Compliance Resource Portal

OIG WorkPlan

The Office of Inspector General's (OIG) work planning process is dynamic and adjustments are made throughout the year to meet priorities

Auditing Information Articles

Click the article title to view a summary and link to the full article.

How to Report Co-Surgeons Using Modifier 62

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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 ...

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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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Nine New Codes for Fine Needle Aspirations (FNA)

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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 ...

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Auditing looking between the lines

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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...

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Billing 99211 Its not a freebie

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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...

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We've Always Done It This Way and Other Challenges in Education

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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...

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Prolonged Services Its Not Just About Time

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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 ...

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When to Use Modifier 25 and Modifier 57 on Physician Claims

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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...

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The Potential Impacts of a Flat Rate EM Reimbursement on our Industry

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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...

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Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement

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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...

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When Medical Necessity and Medical Decision Making Don't Match

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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...

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Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?

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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 ...

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Inappropriate Use of Units Costs Practice Over $800,000

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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?

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Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?

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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...

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Creating a Culture of Compliance in 2018

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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...

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TKAs to Outpatient What We Have Learned with Q1

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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...

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The Devil is in the Data Details

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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.

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Critical Care Documentation

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Critical care documentation should show critical need for the patient AND immediate action by the provider....

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The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?

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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....

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Maximizing Resources for ICD-10 Coding Audits

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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....

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The Comprehensive Error Rate Testing Program

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With nearly a million physicians in this country, how do auditing organizations determine whom to audit?

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The Comprehensive Error Rate Testing Program

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With nearly a million physicians in this country, how do auditing organizations determine whom to audit?

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Scoring & Reporting Your Audit Findings

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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.

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Developing Coding Policies for Compliance

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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 ...

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NEW on Find-A-Code...National Coverage Determinations (NCDs)

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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. ...

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Auditing Information Tips


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  • HCC Coder
  • Find-A-Code Professional
  • Find-A-Code Facility Base

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Auditing Information Webinars

Click the webinar title to view a summary and link to the webinar video.

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

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

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Surgical Coding and Auditing

Ever wonder what an auditor is looking for when they review your surgical coding? Join Aimee and review the basic rules and documentation requirements. We’ll tear apart a couple of operative reports, code them, review NCCI edits, modifiers, and more. Get an idea of how you are doing and things you may want to incorporate into your practice to be better prepared when an audit comes your way. Also, we’ll review our cool Code-A-Note tool and how it can help you locate CPT and ICD-10-CM codes quickly. This tool is great for new coders, coders new to a specialty, difficult coding situations, or anyone who just wants a second opinion on their code options.

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Evaluation and Management Self Audit for Beginners, Part 3: Examination

Evaluation and Management Self Audit for Beginners, Part 3: Examination

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Evaluation and Management Self Audit for Beginners, Part 4: Medical Decision Making

Evaluation and Management Self Audit for Beginners, Part 4: Medical Decision Making

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How to Check NCCI Edits Using FindACode

How to Check NCCI Edits Using FindACode

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"The Dental Office" CDT Codes, Crosswalking to CPT, and Dental Auditing

Join Aimee Wilcox in an informative webinar on procedural coding for the dental office, how CDT codes crosswalk to CPT codes for medical billing, and auditing concerns to watch for.

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Evaluation and Management Coding and Auditing

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).

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Complete & Easy HIPAA Compliance

A simple and practical guide to implementing HIPAA, HITECH, and Omnibus Final Rule components. Includes the forms and policies and information you need to meet compliance requirements. Plus over 50 customizable forms!


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