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.
Click the article title to view a summary and link to the full article.
How to Report Co-Surgeons Using Modifier 62
January 10th, 2019
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published January 10th, 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 ...
Are You Protecting Your Dental Practice From Fraud?
January 10th, 2019
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | 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 ...
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | 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 ...
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...
By BC Advantage | 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...
We've Always Done It This Way and Other Challenges in Education
October 19th, 2018
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...
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 ...
When to Use Modifier 25 and Modifier 57 on Physician Claims
October 1st, 2018
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...
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
September 26th, 2018
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...
Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement
September 11th, 2018
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...
When Medical Necessity and Medical Decision Making Don't Match
August 3rd, 2018
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...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
July 18th, 2018
By NAMAS | 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 ...
Inappropriate Use of Units Costs Practice Over $800,000
June 11th, 2018
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?
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
June 8th, 2018
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...
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...
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...
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.
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
April 20th, 2018
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....
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....
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.
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 ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
January 23rd, 2018
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | 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. ...
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 ...
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?
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.....
Your NAMAS Weekly Auditing & Compliance Tip for October 6, 2017
October 6th, 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 ...
Acronyms and Abbreviations: When You Fall into the Grey Area
October 6th, 2017
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....
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......
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.....
Double Dipping in the History of the Evaluation and Management Note
September 14th, 2017
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | 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 ...
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 ...
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 ...
Don’t Overlook Diagnosis Codes During Coding Audits
July 14th, 2017
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 ...
Focus Audit Results on the Documentation, Not the Encounter
June 30th, 2017
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 ...
Documentation: Carrying Forward or Ineffective Use of Templates
June 30th, 2017
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 ...
Penalties Under the False Claims Act Have Risen for the Second Time Within the Last 12 Months
June 30th, 2017
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 ...
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 ...
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 ...
Ashby’s Law of Requisite Variety; A Lesson in Preparedness
June 30th, 2017
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 ...
Consultation or Transfer of Care, What are the Differences?
June 30th, 2017
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 ...
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 ...
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 ...
Sanction Screening and Evaluating Employee Suitability: The New “Seventh Element” of Compliance
June 30th, 2017
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 ...
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 ...
Diagnosing, Documenting, and Coding for Radiculopathy
June 30th, 2017
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 ...
Outpatient Physical Therapy Changes Effective June 13th, 2017
June 30th, 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 ...
The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims
June 30th, 2017
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 ...
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 ...
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 ...
Think Outside the Box When Auditing Physical Exams
June 29th, 2017
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, ...
To Disclose or Not to Disclose… That is the Question
June 29th, 2017
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 ...
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 ...
Focus on Clinical Documentation to Improve Coding and Audit Results
June 29th, 2017
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 ...
Prescription Drug Management: Is it a Level 3 or a Level 4?
June 29th, 2017
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 ...
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 ...
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 ...
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 ...
DOJ Announces $4.7 Billion in False Claims Act Recoveries: But What Does That Really Mean?
December 30th, 2016
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 ...
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.
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.
2017 CPT Updates Bring Big Changes to Physical Therapy
December 4th, 2016
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 ...
Risk Adjustment and Hierarchical Condition Category Coding and Auditing
December 2nd, 2016
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 ...
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 ...
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 ...
The “APSO” Note: Changes and Challenges with the Modern Patient Record
November 4th, 2016
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 ...
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 ...
Auditing Same Day Psychotherapy and E&M Services: The Time Trap
October 28th, 2016
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 ...
Think Outside the Box When Auditing Physical Exams
October 22nd, 2016
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, ...
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 ...
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 ...
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 ...
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 ...
Documentation Rules vs. Guidelines – Is it Just Semantics, or Something More?
September 23rd, 2016
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 ...
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 ...
Who Can It Be Knocking at Your Door? Are You Prepared?
September 9th, 2016
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 ...
Little Things People Hate About Their Colleagues – Are You Guilty?
September 2nd, 2016
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
June 28th, 2016
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 ...
Study the Rules Before Auditing E&M Services by Teaching Physicians
June 24th, 2016
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 ...
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.
Comparative Billing Reports (CBRs): The Truth About Your Numbers
June 17th, 2016
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 ...
Medical Necessity & Its Impact on E/M Services: Ensure You Always Land on the Correct Level of Service
June 10th, 2016
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) ...
Electronic Medical Records: Is Your EMR Making You Look Like a Bad Doctor?
June 3rd, 2016
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 ...
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 ...
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 ...
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 ...
This Week’s Auditing & Compliance Tip Comes from a Recent NAMAS Q&A
May 6th, 2016
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 ...
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 ...
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 ...
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.
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 ...
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) ...
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 ...
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 ...
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 ...
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 ...
Employee Exclusions Screenings Must be High Priority
February 24th, 2016
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.
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, ...
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.
Patient Status: Hospital Inpatient vs. Observation
February 12th, 2016
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 ...
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 ...
Will Incident-To in Your Organization Pass a Compliance Audit?
February 1st, 2016
By Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | 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.
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 ...
Think Outside the Box When Auditing Physical Exams
January 22nd, 2016
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, ...
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...
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...
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...
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...
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...
Chief Complaint - Rules related to the Chief Complaint in the D.G.
December 2nd, 2015
By Codapedia | 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...
Past medical, family and social history - Documenting and auditing the history section of an E/M service
December 2nd, 2015
By Codapedia | 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...
History of the present illness - HPI Rules from the Documentation Guidelines
December 2nd, 2015
By Codapedia | 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...
It’s a home health crackdown, but your phone’s going to ring
December 2nd, 2015
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...
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...
CMS puts the brakes on RAC audits for now, and implements changes for when they return
December 2nd, 2015
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...
CMS looking for ways to boot providers who don’t correct repeated billing problems
December 2nd, 2015
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...
CMS clarifies the ways physician practices can respond to additional documentation requests
December 2nd, 2015
By Codapedia | 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...
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...
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...
You do not need to change or rewrite your original orders
November 24th, 2015
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 ...
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 ...
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
August 19th, 2015
By Brandy Brimhall | 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 ...
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 ...
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 ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
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 ...
By Brandy Brimhall | 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 ...
By | Published December 4th, 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 contains information about each zone as well as activity and updates in those regions.
ZPIC
Zone
States in Zone
Safeguard Services (SGS)
1
California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands
Health Integrity
(subcontractor ...
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Brandy Brimhall | 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 contains information about each zone as well as activity and updates in those regions.Â
ZPIC
Zone
States in Zone
Safeguard Services (SGS)
1
California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands
Health Integrity
(subcontractor ...
By Brandy Brimhall | 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 ...
Conducting a Gap Analysis for Your Documentation & Billing Systems
November 17th, 2014
By Brandy Brimhall | 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 ...
By Christine Taxin | 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 ...
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
October 16th, 2014
By Brandy Brimhall | 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 ...
The Role of Statistical Analysis in Fighting Fraud
October 16th, 2014
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.
By Chris Woolstenhulme, QCC, CMCS, 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 ...
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, ...
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
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.
"The Dental Office" CDT Codes, Crosswalking to CPT, and Dental Auditing
January 14th, 2019
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.
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).
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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