Clinical Documentation Improvement
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According to the OIG- Insufficient documentation accounted for 87.8 percent of improper payments for surgical dressings, see MLN: PROVIDER COMPLIANCE TIPS FOR SURGICAL DRESSINGS
Clinical documentation improvement (CDI) is the process of producing detailed medical documentation accurately representing a patient's clinical status into coded data. CDI is used to provide information to all members of a patient's care team, facilitate improved patient care, disease tacking, outcomes and medical research , maximize claims reimbursement, and improve data collection and analysis.
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Diagnosis Related Group (DRG) Codes
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Provider Documentation Guides™ (PDGs)
Help providers understand what needs to be documented
AHA Coding Clinic®
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Search NCDs, LCDs, and Articles for Documentation Requirements, Limitations of Coverage, and/or Medical Necessity.
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HCC Code Listing
Review CMS, ESRD, HHS and Rx HCCs
HCC Risk Calculator
Easily calculate HCC risk scores based on diagnoses and other key factors
Berenson-Eggers Type of Service (BETOS) Codes
Review the BETOS code listing
Eliminate Claim Errors
Code Suggestion Tool
NCCI Editors - Validate CCI Edits (Prevent Denials)
See Errors and Warnings, prior to claim submission
E/M Code Calculator
These E/M calculators will help ensure providers are selecting the proper E/M codes.
Additional Links and Resources
CMS- Clinical Data Elements
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October 15th, 2021
Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?
Published October 15th, 2021 - Last Review/Update October 19th, 2021|
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?
October 6th, 2021
ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines
Published October 6th, 2021|
We always knew there would come a day when payers would look down on an "unspecified" diagnosis code and possibly even deny it or delay payment until a review of the record could be performed. ICD-10-CM was adopted by the U.S. for data analytics, which cannot be accurate if unspecified codes are reported when the documentation verifies greater specificity. Join us for a look at the many guideline changes to ICD-10-CM, a review of the newest code changes and suggestions on documentation improvement to elevate coding protocols.
October 4th, 2021
Watch out for New ICD-10-CM Codes
Published October 4th, 2021|
New ICD Codes for: Low Back Pain, Cervicogenic Headache, Non-Radiographic Axial Spondyloarthritis (nr-axSpA), and Social Determinations of Health (SDOH). These codes became effective on October 1, 2021.
September 2nd, 2021
Polysomnography Services Under OIG Scrutiny
Published September 2nd, 2021|
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
June 1st, 2021
Managed Care Organizations Use CMS Tools to Identify Outliers
Published June 1st, 2021 - Last Review/Update June 2nd, 2021|
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.
May 18th, 2021
OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment
Published May 18th, 2021|
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
March 18th, 2021
How Reporting E/M Based on Time May Lose Money
Published March 18th, 2021|
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
March 10th, 2021
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
Published March 10th, 2021|
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
November 18th, 2020
Cross-A-Code Instructions in Find-A-Code
Published November 18th, 2020|
Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
October 12th, 2020
Medicare Improper Payment Report for Chiropractic (2019)
Published October 12th, 2020|
CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...
October 12th, 2020
Medicare Improper Payment Report for Behavioral Health Services (2019)
Published October 12th, 2020|
CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report, behavioral health services have some of the highest Part ...
October 12th, 2020
Medicare Improper Payment Report (2019)
Published October 12th, 2020|
The Medicare Improper Payment Report for 2019 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July ...
July 28th, 2020
OIG Report Highlights Need to Understand Guidelines
Published July 28th, 2020|
A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.
May 5th, 2020
ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting
Published May 5th, 2020|
The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI). The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms. ICD-10-CM Official Coding Guidelines - ...
April 21st, 2020
Special COVID Laboratory Specimen Coding Information
Published April 21st, 2020|
With all the new laboratory test codes that have been added due to the current public health emergency (PHE), there are a few additional guidelines CMS has released about collecting samples to perform the testing. Please keep in mind that these guidelines are by CMS and may or may not apply to other commercial payer policies.
April 20th, 2020
Dismal OIG Report on Telemedicine
Published April 20th, 2020|
Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.
January 30th, 2020
Medicare Announces Coverage of Acupuncture Services
Published January 30th, 2020|
On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
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