Auditing Information

Find-A-Code Tools and Resources

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.

NCDs

National Coverage Determinations

PDGs- Provider Documentation Guides

PDGs- Provider Documentation Guides

Scrub-A-Claim

Scrub-A-Claim

Commercial Payer Policies

Commercial Payer Policies

Find-A-NPI

Find-A-NPI

ICD-10-CM Official Guidelines

ICD-10-CM Official Guidelines for Coding and Reporting

ICD-10-PCS Official Guidelines

ICD-10-PCS Official Guidelines for Coding and Reporting

NAMAS

NAMAS

National Alliance of Medical Auditing Specialists

NAMAS Self Assessment

Identify the medical audit training you need!

NAMAS Podcast

Auditing & Compliance Tips and Weekly Webinars

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

OIG Exclusion List

LEIE Downloadable Databases

RAT-STATS - Statistical Software

OIG-Free software to assist in a claims review

Additional Links and 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

Billing Requirements for OPPS

Billing Requirements for OPPS Providers with Multiple Service Locations

HCUP Inpatient Payer Data

HCUP - Healthcare Cost and Utilization Project

Noridian: Quick Reference Billing Guide

Noridian: Quick Reference Billing Guide

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

Select the title to see a summary and a link to the full article.

How Would Your Organization Defend This Auditing Accusation?

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The Office of Inspector General (OIG) is always working on audits in a pursuit of accurate reporting and reimbursement. A recently published OIG audit report can provide great information on how to protect providers and risk adjustment payers from serious financial losses by showing exactly what the OIG is looking for and how the payer (or provider) may have defended their coding choices. In this article, you will see how the OIG audited the HCC for major depressive disorder and what Anthem did to defend its reporting.

DMEPOS Items: Medical Record Documentation

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According to MLN Connects 2022-04-21 MLNC, "For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for: Type and quantity of items ordered Frequency of use (or replacement if applicable) The medical record should include the patient’s ...

Preventive Services

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In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...

$636 Million in Overpayments Made by Medicare to Providers for Neurostimulators

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According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step ...

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

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

Medicare Auditors Caught Double-Dipping

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

Will Your Critical Care Services Pass An Audit?

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Critical Care Services (CCS) have unique guidelines which may vary between payers. This article explores these differences to help providers to understand what needs to be documented in order to support medical necessity and meet the criteria for the code description.

PDPM Grouper for Skilled Nursing

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The additional grouper for Skilled Nursing, sometimes referred to as (PDPM), is used for classifying SNF patients in a covered Part A stay. This grouper is included with our Home Health Grouper.  Current groupers/calculators include: Home Health PDGM (Patient-Driven Grouping Model) Skilled Nursing Facility PDPM (Patient-Driven Payment Model) What is it? According to CMS, In ...

Lessons Learned from an RADV Audit Report

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If given an opportunity to know ahead of time the questions that would be asked of you in an upcoming interview or quiz, it is likely the outcome would be significantly better than if you were surprised by the questions. This same concept may be applied to audits of risk ...

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

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

Staging and Grading Periodontitis

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We now understand periodontitis may present itself as a manifestation of systemic diseases in fact; according to DeltaDental, research shows that more than 90 percent of all systemic diseases have oral manifestations, including swollen gums, mouth ulcers, dry mouth, and excessive gum problems. Some of these diseases include: Diabetes Leukemia Oral cancer Pancreatic cancer Heart ...

Is Coding Based on Addendums or Late Entries Putting You At Risk of Audit Failure?

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Independent Health, another Medicare Advantage Organization, has been named in a qui tam (whistleblower) lawsuit and enjoined by the DOJ for allegations of fraudulently upcoding to increase beneficiary risk adjustment scores to obtain higher reimbursement. It appears they used DxID, LLC, a coding consulting subsidiary of Independent Health to retrospectively identify and have providers addend unsupported diagnoses. How is your organization actively protecting against accusations of upcoding by improper use and reporting of diagnoses from provider addenda?

Managed Care Organizations Use CMS Tools to Identify Outliers

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Managed Care Organizations (MCOs) include risk-adjusted plans whose funding is based on the health status of their beneficiaries. Government-funded MCOs use CMS information to search for suspected cases of fraud and abuse.

The OIG Turns their Gaze to Possible Inpatient Service Upcoding

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The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...

New Procedure Codes for the Janssen COVID-19 Vaccine

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On January 19, 2021, the AMA announced two new CPT codes for reporting the Janssen Pharmaceutica (a division of Johnson & Johnson) COVID-19 vaccine. Of course, just as with the other COVID-19 vaccines, they must be given FDA approval for Emergency Use Authorization (EUA) to be administered before the codes can be reported. As is ...

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

May 5, 2022 : Do Minor Procedures Feel like Major Work?

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April 14 2022 : Reporting Telemedicine Services by Aimee Wilcox

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February 8, 2022 - Medicare Audit, Do-it-yourself

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