Claims Articles and Resources
News and Important Information
See also Chapter 1 - Insurance & Reimbursement in Find-A-Code's specialty specific Reimbursement Guides or the ChiroCode DeskBook for important claims processing information.
Additional Links and Resources
Billing Requirements for OPPS
Billing Requirements for OPPS Providers with Multiple Service Locations
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June 30th, 2022
More Audits and More Problems
Published June 30th, 2022|
More audits are coming, how do we stay compliant? We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers...
May 10th, 2022
DMEPOS Items: Medical Record Documentation
Published May 10th, 2022|
According to MLN Connects 2022-04-21 MLNC, "For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for: Type and quantity of items ordered Frequency of use (or replacement if applicable) The medical record should include the patient’s ...
May 9th, 2022
Making the Case for Clean Claims
Published May 9th, 2022|
Medicare providers are your claims clean? Federal regulations mandate that 90 percent of “clean claims” must be paid to healthcare providers within 30 days. But what if the payor doesn’t pay within 30 days? What if your claims are unclean? The problem is – who determines what a...
March 31st, 2022
$636 Million in Overpayments Made by Medicare to Providers for Neurostimulators
Published March 31st, 2022|
According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step ...
February 24th, 2022
Split/Shared Visits No Longer Specific to Medicare Plans in 2022
Published February 24th, 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.
February 9th, 2022
How Soon Will the United States Adopt ICD-11?
Published February 9th, 2022|
The ICD-11 diagnostic codeset went into effect worldwide on January 1, 2022 and has been adopted by some countries while others are still considering implementation, including the United States. The changes from ICD-9 to ICD-10 were significant but the change to ICD-11 will include the addition of new chapters, concepts, and symbols like the ampersand (&). Take a minute to familiarize yourself with this diagnostic coding set. The goal is to adopt a single version that has the flexibility to accommodate future code revisions and additions.
October 28th, 2021
Understanding ASCs and APCs: Indicators and Place of Service
Published October 28th, 2021|
The decision regarding the most appropriate care setting for a given surgical procedure is determined by the physician based on the patient's individual clinical needs and preferences. Of course, there is a difference in reimbursement, and the billing depends on where the procedure took place, such as an office setting, inpatient ...
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?
September 29th, 2021
Published September 29th, 2021|
Injection Service Codes Injection service codes, are reported under administration of vaccines/toxoids, using 96372, 90460, 90461, 90471, 90472, 0001A, 0002A, 0003A, 0011A, 0012A, 0021A, 0022A, 0031A, 0041A, and 0042A. Other injections services include: Non-antineoplastic hormonal therapy injections – 96372 Anti-neoplastic nonhormonal injection therapy 96401 Anti-neoplastic hormonal injection therapy- 96402 Allergen immunotherapy - 95115-95117 According to CMS, do ...
August 4th, 2021
Understanding How Place of Service Codes Work
Published August 4th, 2021|
The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ...
June 29th, 2021
Compliance in the Dental Office or Small Practice
Published June 29th, 2021|
If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...
May 12th, 2021
Since When did Dental Claims Require Diagnosis Codes?
Published May 12th, 2021|
The objective of the Accountable Care organization is to integrate and consolidate patient care management to improve patient outcomes. Changes and coordination of dental and medical care are already becoming more apparent when dental offices are being required to bill a patient's medical plan for dental visits due to an ...
May 3rd, 2021
UB-04 Claim Form
Published May 3rd, 2021|
The UB-04 Claim Form, also known as CMS-1450, is used for submitting claims for reimbursement for specially designated facilities. The 837i is the electronic version of the form. Much like the 1500 Claim Form, maintained by the National Uniform Claim Committee, the UB-04 Claim Form is maintained by the National Uniform Billing Committee (NUBC) which maintains lists of approved codes used on various fields on the form (e.g., revenue codes, condition codes). Third-party payers, including Medicare, may have their own adaptations of the general instructions published by the NUBC.
March 17th, 2021
Q/A: Why is My Claim Being Denied When I Report a Secondary Diagnosis Code?
Published March 17th, 2021|
Question: Recently my claims to Medicare are being denied when I submit a secondary diagnosis code. I’ve heard that this is happening in several states including Washington, California, and New York. Has there been a recent change in what secondary diagnosis codes are allowed?
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September 4th, 2018
Mandatory Chart Reviews - What You Need to Know
In this webinar, we are going to discuss what a Chart Review is, why it's mandatory, YOUR benefits to conducting our outsourcing a Chart Review along with the general steps for preparing, performing and properly documenting a Chart Review and its findings. Also, learn what to do post Chart Review - what your next steps should be and how to prioritize.
August 7th, 2018
Medicare reviews claims for a variety of reasons. Some are routine and are not a problem for the doctor or the practice. Some are investigatory in nature and indicate a serious potential threat for both the doctor and the practice. Dr. Ron Short will go over the types of reviews and which are routine and which should cause you to lose sleep. In this webinar you will learn: -What routine reviews are and why they are conducted -What reviews are a potential risk -What triggers reviews -When to get help and what kind of help to get
July 31st, 2018
Lift the Cloud: Part 1 of 2
In this presentation, Dr. Gwilliam, a widely renowned auditor and coder, will reveal to you the references he and other auditors use when reviewing your claims and documentation. These include coding books, Medicare guidelines, and private payor policies. Buckle up for a wild ride.
June 26th, 2018
ICD-10 Guidelines for the Chiropractor
Time for a little refresher. You might think you know ICD-10 now that it has been around for a while. The guidelines teach which codes go first, how certain key words are defined, and ensure that you submit the right information on your claim forms. This webinar will be taught by Dr. Evan Gwilliam who helped write ChiroCode's ICD-10 book and is a certified ICD-10 instructor.
May 29th, 2018
The Most Expensive Documentation Mistakes Chiropractors Make
Notes need to give payers the information they need in order to adjudicate your claims. Do your notes include what they need to see? Can you standardize and simplify your note taking process to decrease your administrative burden? In this webinar, Dr. Gwilliam, Certified Coder, Certified Professional Medical Auditor, and Clinical Director for PayDC Chiropractic EHR Software, will show you how to make it easy. He will review examples and boost your confidence that you are doing things correctly.
March 27th, 2018
This presentation will review how risk management is no longer limited to just malpractice claims. It also includes your financial policy. There is now a greater risk of financial loss due to improper discounting and faulty financial and collection policies than ever before. It is widely known that the Office of Inspector General (OIG) and Medicare are cracking down on healthcare fraud and abuse, but what most chiropractors are unaware of, is how widely successful these efforts have been. In this presentation, we will identify the five most dangerous things we face in chiropractic and how to avoid them. All attendees will receive a free sample 1-page financial policy that can be customized for their practice and a link to receive a free risk assessment score for their practice.
January 19th, 2017
What Claim Forms are Revealing
What Claim Forms are Revealing
Can I Perform 2 Untimed Codes at the Same Time?Claims Topic PageClaims Topic Page - ChiropracticData on Application and Coverage Denials - by Government Accountability OfficeDesignation of Authorized Representative Form - by ACAInstaGuide - Complete 1500 Claim Form Filing Instructions - by innoviHealthLINK BROKE- ERISA FAQ Page - by the Dept of LaborMap of States & Jurisdictions - by the National Association of Insurance CommissionersMedicare Claims Processing Manual - Chapter 25Medicare Claims Processing Manual, Chapter 12Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health CentersMedicare Electronic Claims Exemption - by CMSOfficial DOL text regarding internal claims and appeals under PPACAParticipating vs. Non-Participating (Medicare Part B Claims)Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?Reminder to Stop Billing Duplicate Claims by Medicare Learning NetworkScrub-A-Claim by Find-A-Code.comSelf-Funded Plans and the PPACA: Is this the new normal?Timely Claims Filing: Additional Instructions - MedLearn Article by CMSUB-04 FL 17 – Patient Discharge Status CodesUB-04 FLs 39-41 - Value Codes and AmountsUB04 Claim Form Instructions
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