Auditing Information

News and Important Information

What is Medical Necessity and How Does Documentation Support It?

Auditing Looking Between the Lines

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

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

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

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

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

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

A 2020 Radiology Coding Change You Need To Know

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The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...

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Denials due to MUE Usage - This May be Why!

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CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...

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What did I do today?

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What did I do today?   Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...

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Packaging and Units for Billing Drugs

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To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number. Take a look at the following J1071 - Injection, testosterone cypionate, 1mg For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL (100 mg/mL = 1 mL and there are ...

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

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Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

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Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible

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Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...

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Q/A: Is the Functional Rating Index by Evidence-Based Chiropractic Valid?

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Question Is the Functional Rating Index, from the Institute of Evidence-Based Chiropractic, valid and acceptable? Or do we have to use Oswestry and NDI? Answer You can use any outcome assessment questionnaire that has been normalized and vetted for the target population and can be scored so you can compare the results from ...

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Q/A: What if my Patient Refuses to Fill out the Outcome Assessment Questionnaire?

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Question: What if my Medicare patient refuses to fill out the outcome assessment questionnaire? Answer: Inform the patient that Medicare requires that you demonstrate functional improvement in order for them to determine if the care is medically necessary. In other words, they may have to pay for the care out of pocket if ...

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The Slippery Slope For CDI Specialists

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Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.  Many of you in this industry are ...

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Tips to Preventing Audits

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There is an ever-increasing number of dental claims that 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 billing practices. When payers identify the activities they deem ...

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Helping Others Understand How to Apply Incident to Guidelines

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Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...

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A United Approach

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A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

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

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Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

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What to Look for When Auditing Smoking Cessation Services

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What to Look for When Auditing Smoking Cessation Services

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

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Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942? Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...

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Let's Talk High Risk E/M Services

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Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.   Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...

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What is Medical Necessity and How Does Documentation Support It?

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We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

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Prepayment Review Battle Plan

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Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...

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

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I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"  The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

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Type of Bill Code Structure (2018-08-30)

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The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form. Type of bill codes are four-digit codes that describe the type of bill a ...

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Understanding NCCI Edits

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Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

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Coding Medicare Initial Preventive Physical Exams (IPPE)

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The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...

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Clinical Staff vs. Healthcare Professional

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State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.  Physician or other qualified healthcare professionals:  Must have a State license, education training showing qualifications as well as facility privileges.  Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...

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How to Report Co-Surgeons Using Modifier 62

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Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...

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Are You Protecting Your Dental Practice From Fraud?

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With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...

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Nine New Codes for Fine Needle Aspirations (FNA) in 2019

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If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...

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

Rock Solid Care Plans

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.

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Coding Auditing Evaluation and Management and 2019

Coding Auditing Evaluation and Management and 2019

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

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

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Pain in the Ass*essment

In this webinar, Dr. Friedman will discuss how the Assessment may be the most misunderstood aspect of our documentation and how we can document it properly and quickly so it shows how the patient is progressing with care.

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Conducting Your Own Chart Audit: Part 2 of 2

In Part 1, Dr. Gwilliam shared with you where auditors and claim reviewers get their information from. Now it is your turn. Dr. Gwilliam will guide you through some of the criteria and systems he uses when reviewing charts for attorneys and doctors. Bring your 2018 DeskBook along because Appendix D will be your friend as you figure out how to keep mistakes out of your practice.

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Lift the Cloud: Part 1 of 2

In this presentation, Dr. Gwilliam, a widely renowned auditor and coder, will reveal to you the references he and other auditors use when reviewing your claims and documentation. These include coding books, Medicare guidelines, and private payor policies. Buckle up for a wild ride.

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Evaluation and Management Coding and Auditing

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

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Surgical Coding and Auditing

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

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Essential Elements of a Care Plan

Creating effective care plans and using them properly is the solution to most clinic's documentation issues. Once you make it clear to auditors and reviewers what the game plan is, and you show that you follow it throughout care, communication issues will be eliminated and you will be able to manage the case better. In this presentation, Dr. Gwilliam, Clinical Director for PayDC Software, and former Vice President of ChiroCode, will review fundamental concepts of care plans, as outlined in Chapter 4.4 of the DeskBook, and show how it is done in one chiropractic EHR. You will leave the webinar with a clear path to improve your care plans so that you can be confident that third parties understand your records.

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2018 Coding and Documentation Issues for DCs

The new year is coming. Are you ready? Do you know which codes have changed? Do you know which issues are the focus of payers and auditors? Have you conducted annual reviews to make sure nothing is falling through the cracks? Join Dr. Gwilliam of PayDC Software, as he helps you prepare for 2018.

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Conducting a Self-Audit

As part of a good compliance plan, and just because it is smart, you should be conducting at least annual audits in your office. If done right, you should be able to catch problems before some insurance company comes after you and demands money back. In the new 2018 DeskBook, we have provided you with self audit forms that you can copy and place in your Compliance Manual as evidence of your efforts to improve. Solutions for identified deficiencies are also right at your fingertips. In this presentation, Dr. Gwilliam will teach you how to audit yourself and keep the external auditors away.

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Audit Your Evaluation Visits

In this webinar, get a sneak peak at how ChiroCode audits a typical evaluation encounter. Do you document functional loss? Are you using outcome assessment tools appropriately? Does your treatment plan include measurable goals? Do you document complicating factors? Answer all these questions and more in this action-packed half hour with Dr. Gwilliam.

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How to Check NCCI Edits Using FindACode

How to Check NCCI Edits Using FindACode

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

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

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

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

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Q & A with the Experts

Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA & Brandy Brimhall CPC CMCO CPCO CCCPC October 11, 2016 Tuesday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST In this special webinar, Dr. Gwilliam, VP of ChiroCode, and Brandy Brimhall, Director of Education for ChiroCode, will have no presentation prepared for you. Bring you most pressing questions and get free, unfettered access to two of the most highly credentialed coders/auditors in chiropractic. This is your chance to pick their brains and figure out how to get paid properly for the work you do.

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

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

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Evaluation and Management Self Audit for Beginners, Part 2: History

Evaluation and Management Self Audit for Beginners, Part 2: History

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Evaluation and Management Self Audit for Beginners, Part 1: Fundamentals

Evaluation and Management Self Audit for Beginners, Part 1: Fundamentals

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Documenting a Thorough New Patient First Visit Quickly

Presented by Gregg Friedman DC July 5, 2016 Tuesday @ 10:15 PM PT, 11:15 PM MT, 12:15 PM CT, 1:15 PM ET Dr. Friedman will discuss the importance of starting the documentation process with the new patient correctly and how to get the most thorough information in the least amount of time.

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Audits – How can you Protect Your Practice?

Presented by David Klein, CPC, CPMA, CHC May 17, 2016 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET For several years the chiropractic profession has been inundated with warnings, rumors, and other anecdotes about audits - some true, and others, not so much. This webinar cuts through the rhetoric and presents the basics: what are audits and how are they conducted; what should a practice do if subjected to an audit; and how you can prepare before an audit occurs.

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DeskBook 101: Evaluation and Management Self Audit

Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA April 19, 2016 Tuesday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 EST Chapter 5.3 of the 2016 ChiroCode DeskBook is all new, with tables and examples to help you become an expert on E/M coding for chiropractic. E/M codes are a top target by auditors because many providers use them incorrectly, or trust their EHR system templates to do the work for them. In this webinar, find out how to audit your own E/M codes so you don't have to fear the auditors.

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Complete & Easy HIPAA Compliance

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



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