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Viewing:  Jul 20, 2019

Auditing Information

What is Medical Necessity and How Does Documentation Support It?

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Auditing Looking Between the Lines

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I. 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.

II. NAMAS

NAMAS

National Alliance of Medical Auditing Specialists

NAMAS Self Assessment

Identify the medical audit training you need!

III. 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

IV. 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

V. 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

I. Find-A-Code Tools and Resources

NCDs

National Coverage Determinations

Auditing Information Articles

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

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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2018 Salary Survey

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NAMAS needs your help in capturing salary information for 2018 and developing standards for the industry. This is the information that YOU as an auditor need to share with your employer! Everyone who participates will be entered into a drawing for a chance to win one of many prizes! One winner ...

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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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Auditing looking between the lines

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When given the task of auditing a group of charts, most often the scope of the audit is well defined. For me, there are times when my natural inquisitive nature turns on and I find my noticing the "timing" of parts of documentation. These are things that you would not...

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Billing 99211 Its not a freebie

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It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...

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

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As coders, auditors, and compliance professionals, we are the provider's advocates in closing the gap between what is medically necessary and what is required for documentation. Sometimes that places us in the role where we need to save our clinicians from themselves, and the patterns they have fallen into...

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Wolters Kluwer Drug Pricing

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Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...

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Prolonged Services Its Not Just About Time

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Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter. However, a ...

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When to Use Modifier 25 and Modifier 57 on Physician Claims

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The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...

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

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The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...

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

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We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...

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When Medical Necessity and Medical Decision Making Don't Match

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As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...

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

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Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.   For ...

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Inappropriate Use of Units Costs Practice Over $800,000

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A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?

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

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Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...

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The Range of Motion Conundrum

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As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...

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Auditing Therapy Evaluation Codes - Not So Quick!

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New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...

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Creating a Culture of Compliance in 2018

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This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...

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TKAs to Outpatient What We Have Learned with Q1

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The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...

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The Devil is in the Data Details

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As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.

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Critical Care Documentation

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

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

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As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....

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Maximizing Resources for ICD-10 Coding Audits

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From internal reviews to external inpatient coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind....

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The Comprehensive Error Rate Testing Program

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

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The Comprehensive Error Rate Testing Program

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

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Scoring & Reporting Your Audit Findings

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This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.

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Developing Coding Policies for Compliance

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Every physician practice depends upon correct coding and billing for their financial success. Coding drives reimbursement. All of the resources available for coding information and guidance are meaningless without the practice manager translating it into provider-specific coding policies and compliance plan. As a practice manager, you need to develop a ...

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

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Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...

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Auditing Information Tips


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  • HCC Coder
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Auditing Information Webinars

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Coding and Billing Chronic Care Management Services

Coding and Billing Chronic Care Management Services ...

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Coding and Billing Updates for Telemedicine Services

Coding and Billing Updates for Telemedicine Services ...

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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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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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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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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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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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