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

Payment Adjustment Rules for Multiple Procedures and CCI Edits - Find-A-Code Spotlight Articles

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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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.

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CMS- Clinical Data Elements

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


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?

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ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines


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.

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Watch out for New ICD-10-CM Codes


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.

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​​Polysomnography Services Under OIG Scrutiny


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?

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Managed Care Organizations Use CMS Tools to Identify Outliers


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.

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OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment


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.

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How Reporting E/M Based on Time May Lose Money


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 ...

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How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment


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.

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Cross-A-Code Instructions in Find-A-Code


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.

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Medicare Improper Payment Report for Chiropractic (2019)


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 ...

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Medicare Improper Payment Report for Behavioral Health Services (2019)


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 ...

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Medicare Improper Payment Report (2019)


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 ...

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OIG Report Highlights Need to Understand Guidelines


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.

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ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting


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 - ...

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Special COVID Laboratory Specimen Coding Information


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.

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Dismal OIG Report on Telemedicine


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.

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Medicare Announces Coverage of Acupuncture Services


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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ACA Clarifies Aetna PolicyAetna Physical Therapy PolicyAmerican College of Radiology Practice Parameter for Communication of Diagnostic Imaging FindingsCan I Perform 2 Untimed Codes at the Same Time?Chiropractic Software-Generated Documentation by NoridianCMS Meaningful Use Registration and Attestation WebsiteCMS-Novitas Solutions: E/M Documentation Auditor's InstructionsCMS-Novitas Solutions: Specialty Exam: CardiovascularCMS-Novitas Solutions: Specialty Exam: DermatologyCMS-Novitas Solutions: Specialty Exam: Ears, Nose and ThroatCMS-Novitas Solutions: Specialty Exam: EyesCMS-Novitas Solutions: Specialty Exam: Genitourinary (Female)CMS-Novitas Solutions: Specialty Exam: Genitourinary (Male)CMS-Novitas Solutions: Specialty Exam: Hematologic/Lymphatic/Immunologic ExaminationCMS-Novitas Solutions: Specialty Exam: MusculoskeletalCMS-Novitas Solutions: Specialty Exam: NeurologyCMS-Novitas Solutions: Specialty Exam: RespiratoryCoding and Billing WorkshopsCoding_Changes_2014Complaince Program Guidance for Third-Party Medical Billing CompaniesCompliance Program Guidance for Ambulance SuppliersCompliance Program Guidance for Clinical LaboratoriesCompliance Program Guidance for Home Health AgenciesCompliance Program Guidance for HospicesCompliance Program Guidance for HospitalsCompliance Program Guidance for Individual and Small Group Physician PracticesCompliance Program Guidance for Medicare+Choice OrganizationsCompliance Program Guidance for Nursing FacilitiesCompliance Program Guidance for Pharmaceutical ManufacturersCompliance Program Guidance for the Durable Medical Equipment, Prosthetics, Orthotics, and Supply IndustryCR 5550 Clarification - Signature Requirements by CMSDetails about EHR Incentive ProgramDocumentation Topics PageEHR Topics PageGastro_ArticleGeriatricHealth Behavior Assessment and Intervention Billing and Coding Guide by the APAHHS, Justice Department warn hospitals on EHR-related payment fraudHHS/CMS Letter Regarding Cloning RecordsHIPAA regulations and sign-in sheets - by HHSHome Health Billing FAQsImpairment Rating GuidesInappropriate Medicare Payments for Chiropractic Services Report - by the OIGInjury and Illness Recordkeeping RequirementsMedicare Advantage Plans: Cost Sharing LimitsMedicare Documentation Job Aid for Doctors of Chiropractic — MLNMedlinePlusNew Modifiers to Identify Occupational Therapy (OT) and Physical Therapy (PT) Services Provided by a Therapy AssistantNoridian Documentation ChecklistsNoridian Review of A5500 (Therapeutic Shoes)OIG Compliance Program for Individual and Small Group Physician PracticesOIG Compliance Program for Individual and Small Group Physician Practices - Federal RegisterOIG Issues Renewed Focus on Chiropractic ServicesPressure Ulcer GuidelinesProperly Appealing CCI Edit Denials - by ACAProvider Compliance Tips for Diabetic Test StripsProvider Compliance Tips for Hospital Beds and AccessoriesProvider Compliance Tips for Infusion Pumps and Related DrugsProvider Compliance Tips for Laboratory Tests - Blood CountsQuality Payment ProgramRisk classification based on the comprehensive foot examination by American Diabetes AssociationScreening Pap Tests and Pelvic Examinations by CMSSecurity Risk Assessment WizardSonomaSubjective/Objective Findings Necessitating CareSupplemental Compliance Program Guidance for HospitalsSupplemental Compliance Program Guide for Nursing FacilitiesThe Medicare Program Integrity Manual, Chapter 3, Section BThe One-Minute Spinal Outcome Measure

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