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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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.

MS-DRG Grouper

Quickly calculate the correct DRG based on submitted ICD-10-CM and ICD-10-PCS codes

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


DME Documentation


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.

Medicare Improper Payment Report (2021)


The Medicare Improper Payment Report does not measure fraud, but 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 1, 2019 through June 30, 2020, was 93.74%, which is up slightly from last year. The estimated improper payment rate (claims paid incorrectly) was . . .

Medicare Improper Payment Report — Chiropractic 2019 to 2021


How did you do? Take a look at the Improper Payments Report and see where there can be improvement in your practice.

Do You Know What Code is Used to Report Long-Haul COVID-19 Conditions?


A new code was added to the ICD-10-CM official code set with an effective date of October 1, 2022 for reporting post-COVID-19 sequela. We have all heard about people having odd conditions following COVID-19, well now there is a code available for reporting all of these anomalies, but are you familiar with the code and the rules for reporting it?

How Much Do You Care about the 2022 Care Management Service Changes?


Have you already implemented a care management services program in your provider organization? If not, now may be the time to seriously consider doing so. Significant 2022 changes to the codes and increases in RVUs and reimbursement rates creates an opportunity not only to improve patient care for chronic conditions but will also help your practice increase revenues if done correctly.

CMS Claims Risk Adjustment Overpayments Commonly Include 10 Specific Diseases


There are many lessons that can be learned from a single OIG audit report. In this recently-published OIG report, several of the most common documentation and coding errors are pointed out in relation to reporting HCCs for risk adjusted plans. Take a few minutes to review the report and see if improvements within your own organization can be made from what you learn.

How Would Your Organization Defend This Auditing Accusation?


The Office of Inspector General (OIG) is always working on audits in a pursuit of accurate reporting and reimbursement. A recently published OIG audit report can provide great information on how to protect providers and risk adjustment payers from serious financial losses by showing exactly what the OIG is looking for and how the payer (or provider) may have defended their coding choices. In this article, you will see how the OIG audited the HCC for major depressive disorder and what Anthem did to defend its reporting.

Methadone Take-Home Flexibilities Extension Guidance

On March 16, 2020, SAMHSA issued an exemption to Opioid Treatment Programs (OTPs) whereby a state could request “a blanket exception for all stable patients in an OTP to receive 28 days of Take-Home doses of the patient’s medication for opioid use disorder.” States could also “request up to 14 days of Take-Home medication for those patients who are less stable but who the OTP believes can safely handle this level of Take-Home medication.” The exemption will carry on effective upon the expiration of the COVID-19 Public Health Emergency, subject to conditions listed in this article.

Minor Procedures Get a Major Sting in the 2021 CERT Report


The 2021 Comprehensive Error Rate Testing report provides important lessons on exactly what errors are being found during chart reviews and how provider organizations can be proactive in their approach to quality documentation that not only supports the services provided to the patient but allows the providers to work in an environment of knowing what must be documented to support what they submit to the payer.

How to Reduce the Risk of Copy and Paste


Providers should never C&P (copy and paste) material they have not read nor vetted for accuracy. A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his surgery, it was reported that the surgeon referred to “DVT/VTE Prophylaxis/Anticoagulation” and another note read, “already ordered.” “DVT...

Preventive Services


In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...

Split/Shared Visits No Longer Specific to Medicare Plans in 2022


Medicare is making changes to the reporting guidelines for split or shared services. Some important changes have already gone into effect as of January 1, 2022 and others are scheduled to go into effect in 2023. If your organization reports split or shared services, it’s time to look more closely at how the new rules will affect your compliance policies and reimbursement.

Critical Care Services Changes in the Medicare 2022 Final Rule


Critical Care Services — Medicare's final ruling has been released. This article discusses the changes to critical care services, including bundled services, concurrent services, global surgery, time spent performing CCS services, and documentation requirements. It also lists the two new modifiers.

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?

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.

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.

​​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?

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.

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.

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 ...

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

June 2, 2022 : Coding 2022 Care Management Services

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May 5, 2022 : Do Minor Procedures Feel like Major Work?

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April 14 2022 : Reporting Telemedicine Services by Aimee Wilcox

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April 12th, 2022 - What do Chiropractors Need to do to Comply with the No Surprises Act?

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January 11, 2022 - Chiropractic Documentation: The Subjective Element

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November 9th, 2021 - Chiropractic Documentation: The S.O.A.P. Format and Additional Information

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September 14 - Chiropractic Manipulative Treatment: Coding and Documentation

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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.

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Dental Medical Billing & Coding Certification on - Your Dental Certification Destination is the industry leader for dental coding and billing certifications. The credentialing exams are hosted and administered by 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.

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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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