Clinical Documentation Improvement
News & Important Information:
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®
Search the AHA Coding Clinic® Articles by Keywords
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
Select the title to see a summary and a link to the full article.
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 ...
October 1st, 2019
The New ICD-10-CM Code Updates Are Here — Are You Ready?
Published October 1st, 2019|
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...
August 2nd, 2019
The Slippery Slope For CDI Specialists
Published August 2nd, 2019 - Last Review/Update August 8th, 2019|
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 ...
July 22nd, 2019
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
Published July 22nd, 2019|
Question: What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms. Answer: There is no question that these adjustments would be considered ...
July 9th, 2019
The Importance of Medical Necessity
Published July 9th, 2019|
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
June 27th, 2019
2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done
Published June 27th, 2019 - Last Review/Update July 8th, 2019|
The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
Published June 13th, 2019|
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 ...
June 6th, 2019
How to Code Ophthalmologic Services Accurately
Published June 6th, 2019 - Last Review/Update June 11th, 2019|
Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code. According to Article A19881 which was published in 2004 and ...
May 29th, 2019
Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?
Published May 29th, 2019 - Last Review/Update June 4th, 2019|
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
May 13th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices
Published May 13th, 2019 - Last Review/Update May 20th, 2019|
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
May 6th, 2019
Q/A: If Orthopedic Tests are Negative, do You List Them in Your Treatment Notes?
Published May 6th, 2019|
Question: If orthopedic tests are negative, do you need to still list them in your treatment notes? Answer: Yes. Any tests which are performed by a healthcare provider, regardless of the result, should be documented in the patient record. This record is the only way that a reviewer or another provider ...
April 23rd, 2019
Let's Talk High Risk E/M Services
Published April 23rd, 2019|
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 ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
Published April 23rd, 2019|
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 ...
April 22nd, 2019
Auditing Chiropractic Services
Published April 22nd, 2019|
Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.
March 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
Published March 21st, 2019|
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. ...
March 1st, 2019
Understanding NCCI Edits
Published March 1st, 2019|
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 ...
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
Published February 12th, 2019|
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 ...
January 25th, 2019
Medical Necessity vs. Documentation for Inpatient Services
Published January 25th, 2019 - Last Review/Update January 29th, 2019|
Auditing the documentation of inpatient and observation E/M services can often be challenging. Many of the notes we are provided for review include so much information that the note feels like a short novel instead of documentation for one date of service. This over-documentation can make it difficult to see ...
January 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
Published January 23rd, 2019|
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 ...
January 22nd, 2019
Home Oxygen Therapy
Published January 22nd, 2019|
Home Oxygen Therapy Guidelines
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January 28th, 2021
January 28th - New Dental Codes for 2021 and Find-A-Code Dental Tools/Resources
Outline of Presentation: - Why Dental coding is changing - New 2021 Dental Codes - Why Cross Coding is Not a Choice - New Dental Tools & Resources in Find-A-Code Be ready for 2021 with complete understanding of the new dental codes. Understand what codes are not covered under dental, and how to bill with medical codes.
January 21st, 2021
January 21st - Dental Medical Billing & Coding Certification on QPro.com - Your Dental Certification Destination
QPro.com is the industry leader for dental coding and billing certifications. The credentialing exams are hosted and administered by QPro.com. To earn dental-to-medical billing credentials, candidates must pass at least three exams including the requisite Qualified Medical Coder/Biller Exam. From there, candidates can earn designations in nine specializations, such as dental implant coding, oral surgery, sleep apnea, sedation dentistry, and coding and reimbursement for CBCT scans.
January 7th, 2020
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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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 184.108.40.206 BThe One-Minute Spinal Outcome Measure
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