Auditing Information
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News and Important Information
AMA- Payor audits on the rise. How private practices can get ready Video (part 1) Video Part 2 04/11/2022
Article What is Medical Necessity and How Does Documentation Support It? 04/23/2019
BC Advantage Article Auditing Looking Between the Lines 11/30/2018
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OIG
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Select the title to see a summary and a link to the full article. some articles require a subscription to view.
May 22nd, 2024
Be Wary, But not Fearful, of False Claims Act Allegations
by David M. Glaser, Esq.
One of my favorite things to do is help clients extricate themselves from a False Claims Act investigation. I like it because it’s intellectually challenging, and few things are more rewarding than keeping an organization from having to pay large sums of money. Longtime readers know that False Claims...
by Adam Brenman
The Centers for Medicare & Medicaid Services (CMS) can’t seem to catch a break of late. 2023 has been a tough year for the agency, with the court system and Congress dealing it repeated blows, primarily over enactment of the No Surprises Act (NSA). Many are undoubtedly at least...
Sep 6th, 2023
When Is a Shared Visit Not a Shared Visit?
by David M. Glaser, Esq.
Can you do a “shared visit” in a physician clinic, site of service 11? The most common answer to this question seems to be “no,” and while that is technically correct, it is so misleading that it is effectively entirely wrong. To understand this confusion, we need to dig...
Jul 26th, 2023
Understanding Why Laboratories Are Under Scrutiny
by Knicole C. Emanuel Esq.
Laboratories are suddenly under scrutiny by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and state Medicaid departments. Labs get urine samples from behavioral healthcare companies, substance abuse companies, hospitals, and primary care facilities that often don’t have their own labs. Owners of...
Jun 20th, 2023
Be Aware — Emergency Department Visits Under OIG Scrutiny
by Wyn Staheli, Director of Content - innoviHealth
Every year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting.
Jun 8th, 2023
UnitedHealthcare Updates Manipulation Policy
by Wyn Staheli, Director of Content - innoviHealth
UnitedHealthcare has issued a notice that there is a new Manipulation Commercial Payer policy which will become effective on July 1, 2023. Learn about the changes to the “Coverage Rationale” portion of the policy.
May 31st, 2023
The Perils of E&M Codes and Insurance
by Knicole C. Emanuel, Esq.
- ... Continue reading the article at RACmonitor → This article originally published on May 31, 2023, by RACmonitor....
Mar 13th, 2023
2023 E/M Changes — Are You Sure You are Compliant?
by Raquel Shumway
Have you addressed all of the 2023 E/M Changes including the new changes added in March? Have you conducted a self-audit and trained your staff on these changes? Find-A-Code has tools available to help you make sure you are in compliance with these new changes.
Dec 27th, 2022
Compliance Billing: Power Mobility Devices
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The 2023 Evaluation and Management changes have been published and efforts are ongoing to educate coders and provider organizations on the guideline and code description changes that will impact professional coding in the facility setting. These changes required a significant revision to the guidelines and definitions of the various levels of complexity associated with the Number and Complexity of "Problems Addressed" during an encounter, which is the first element of medical decision making (MDM) and the following explanations and examples should provide a greater understanding of the changes headed our way in January.
Oct 24th, 2022
2023 Evaluation & Management Updates Free Webinar
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
by Ronald Hirsch, MD FACP CHCQM CHRI
Three items are discussed in this article: First, performing random audits of critical care visits billed with CPT codes 99291 and 99292 to ensure the patient was truly critically ill, which could help avoid recoupment. Secondly, time will tell if rural hospitals will switch to the rural emergency hospital designation. Lastly, a 2023 OPPS proposed rule, CMS discusses creating a new payment category, paying for software as a service.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
In just a few short months, major revisions to the remaining Evaluation and Management categories in the Current Procedural Terminology (CPT) code book will go into effect. How many of these changes will affect your organization and how ready are you for them? While the changes to the remaining E/M categories will closely resemble the 2021 changes to the E/M Office and Other Outpatient (99202-99215) codes, there are some major differences that need to be carefully reviewed, such as how E/M will change for the Emergency Department services.
Oct 13th, 2022
Are Leading Queries Prohibited by Law or Lore?
by Erica E. Remer, MD CCDS
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
Sep 8th, 2022
Are You Prepared to Avoid Repayments
by Raquel Shumway
Watchful care is needed when submitting claims.
The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Have you heard the saying, "I am getting paid, so I must be doing something right!" Claims get processed and paid incorrectly all the time; the fact is you may be doing something wrong even if you are getting paid! If you don't understand how the physician fee schedule works, ...
by Amanda Ballif
The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.
Jun 30th, 2022
More Audits and More Problems
by Ronald Hirsch, MD FACP CHCQM CHRI
More audits are coming, how do we stay compliant? We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers...
Jun 23rd, 2022
Why You Should Be Using The Two-Midnight Rule
by David M. Glaser, JD
Are you using something other than two-midnight? Here’s why you shouldn’t be. Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has...
There are 12 related documentation, coding and billing tips.
Select the title to see a summary and a link to the full webinar information. some webinars require a subscription to view.
Jul 27th, 2023
Auditing EM Services Using the FAC EM Calculator Tool
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medical decision-making (MDM) is a critical part of code selection for evaluation and management services. It is highly recommended that organizations take time to perform internal audits of billed E/M services to ensure that all required elements are met for the level of MDM reported. Join us for this informative webinar which goes over the different elements of MDM as well as how to use Find-A-Code's Calculator tool to perform your own internal audit.by Ron Short, DC MCS-P CPC
Presented by Ron Short DC, MCS-P, CPC July 11, 2023 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 We are hearing a lot about Medical Decision Making (often abbreviated as MDM) now that it is one of the only two ways to determine the appropriate Evaluation and Management code level. In this webinar Dr. Short will show you: What is Medical Decision Making When does Medical Decision Making occur How Medical Decision Making is important to you How to use Medical Decision Making to your advantage You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list-signup/ (the link to the notes will be in the final welcome e-mail) or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
'Reduce pain" may be a real goal of chiropractic care, but is it enough? While you may want to help your patients to reduce their pain, goals need to focus on what kinds of functions are affected by that pain. Does it keep the patient from sleeping, from sitting at a desk, from washing their hair when in the shower? Learn how to create goals that are easy to defend and use to justify ongoing treatment in this fun-filled webinar by Dr. Evan Gwilliam, a Certified Professional Medical Auditor.Apr 18th, 2023
Medicare’s Rules for Records Requests
by Ron Short, DC MCS-P CPC
Medicare continues to request records in order to determine if a claim is payable. However, they have very specific rules and regulations that they are required to follow in requesting the records and reporting the findings. In this webinar Dr. Short will show you: Who can review your records, what needs to be in the request for records, how long you have to respond to a request for records, how to respond to a request for records, how they are required to report the results of the review. You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list-signup/ (the link to the notes will be in the final welcome e-mail) or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.Mar 9th, 2023
Keeping up to date on reporting changes...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Properly reporting split or shared patient encounters can be tricky. The CPT codebook just began defining this type of encounter and the 2023 Medicare Physician Fee Schedule Final Rule included some changes. Tune into this informative webinar to ensure that you are doing things the right way.Feb 14th, 2023
Use the Right Modifiers for Chiropractic Billing
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Do you really know when to use the 59 modifier? What about the AT? There are relatively few modifiers to consider when it comes to chiropractic billing and coding, but some payers have their own rules and it can be tricky to know when to use one modifier and not another. In this exciting webinar, Dr. Evan Gwilliam, a certified coder, will clear up all the questions you have about the modifiers you need to consider.Jan 25th, 2023
Medical Necessity: it’s far easier to prove than you think, and far more important than you realize.
by Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education
Besides coding errors, it’s the 2nd most common tool used by health insurers and 3rd party payers to deny care and deny liability. How do you decide what to use as a tool to prove your care is viable and needed? Expensive equipment and elaborate testing procedures are not what you need. It’s as simple to prove as opening a can of beans, unless you don’t have a can opener. I’ll share with you my insider tips and experience as a medical expert on over 3000 successful PI case settlements and give the can opener that you and your patients need you to use to prove medical necessity, and why you’ll need it in treating what I feel is the next great opportunity for Chiropractic: V_______ care.Aug 16th, 2022
Medicare and the ABN for Chiropractic
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Medicare can be intimidating, but fortunately, the rules can be made simple and actually reduce anxiety when applied properly. All you need to know about ABNs and Medicare modifiers will all be covered in this presentation so that you can feel confident you know you are doing things right.May 5th, 2022
Do Minor Procedures Feel like Major Work?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 14th, 2022
Reporting Telemedicine Services by Aimee Wilcox
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Anyone who sees patients who have services that are not covered by insurance needs to know about the No Surprises Act. In this quick webinar, Dr. Gwilliam will show you how to properly notify patients of their options and create a Good Faith Estimate, as required by this law. Expect this…Feb 8th, 2022
Medicare Audit, Do-it-yourself
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Don't wait for Medicare to look over your records and try to find deficiencies. Dr. Gwilliam, a Certified Professional Medical Auditor, will show you how to find your own deficiencies, and fix them before they become a compliance or financial concern. This isn't just for Medicare either. If you can…Jan 11th, 2022
Chiropractic Documentation: The Subjective Element
by Ron Short, DC MCS-P CPC
The Subjective element of S.O.A.P. is where we document what the patient tells us. But what is the best way to gather this information? In this webinar Dr. Ron Short will review the guidelines for the subjective element and explain the best way to gather information from the patient.&…by Ron Short, DC MCS-P CPC
We have all heard of the S.O.A.P. format for our documentation. But what does each element mean and what additional information do we need in our documentation? In this webinar Dr. Ron Short will review the S.O.A.P. documentation format and discuss what additional information you need document. In…by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
The most commonly used procedure in chiropractic is the chiropractic adjustment, also known as chiropractic manipulative treatment or CMT. There are nuances to the CPT and ICD-10 codes and Medicare guidelines that must be mastered by any chiropractor hoping to find success when creating their…Jul 8th, 2021
Chiropractic Treatment Paradigm 2021
by Ron Short, DC MCS-P CPC
Chiropractic care is different from medical care. We know that but how do we explain it. Reviewers deny claims that are medically necessary because they don’t know what they are looking at when they review our claims. Dr. Ron Short will explain how to approach these reviewers in this…by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC
August 18, 2020 Join this webinar for a birds-eye review of crucial components of your practice revenue cycle system. Inefficient or unattended revenue cycle systems result in a tremendous loss of time and money for practices. So often, that additional cash flow that practices are seeking, are…Jan 7th, 2020
Rock Solid Care Plans
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Don't ever let anyone challenge your care plans ever again. If you can know what the regulators are looking for while still being free to deliver the care you deem to be best for your patient, then you win. And your patient wins. Join Dr. Gwilliam, certified professional medical auditor, and all around nice guy, as he guides you to the steps to create rock solid care plans that will stand up to third party scrutiny.Jun 27th, 2019
Coding and Billing Chronic Care Management Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Coding and Billing Chronic Care Management Services ...Jun 11th, 2019
Coding and Billing Updates for Telemedicine Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Coding and Billing Updates for Telemedicine Services ...Dec 13th, 2018
Coding Auditing Evaluation and Management and 2019
Coding Auditing Evaluation and Management and 2019
by Find-A-Code™
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.Apr 12th, 2018
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).Jan 25th, 2018
Surgical Coding and Auditing
by Find-A-Code™
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.Feb 2nd, 2017
How to Check NCCI Edits Using FindACode
by Find-A-Code™
How to Check NCCI Edits Using FindACodeby Find-A-Code™
Evaluation and Management Self Audit for Beginners, Part 4: Medical Decision Makingby Find-A-Code™
Evaluation and Management Self Audit for Beginners, Part 3: ExaminationOct 4th, 2016
ICD-10-CM Updates for the Auditor, a NAMAS webinar
by Find-A-Code™
ICD-10-CM Updates for the Auditor, a NAMAS webinarby Find-A-Code™
Evaluation and Management Self Audit for Beginners, Part 2: Historyby Find-A-Code™
Evaluation and Management Self Audit for Beginners, Part 1: FundamentalsLinks and resources by topic.
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