Documentation Articles and Resources

Documentation is essential to establishing medical necessity and the level of services provided to the patient. Treatment plans and Outcomes Assessment Tools (OATs) are crucial required elements required of appropriate documentation.

Please review additional information in the related topics and other resources portions of this topic.

We recommend carefully reviewing Chapter 4-Documentation of Find-A-Code's specialty-specific Reimbursement Guides for a more thorough and detailed explanation of this topic.

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NCD’s/LCD’s/Articles

Search NCDs, LCDs, and Articles for Documentation Requirements, Limitations of Coverage, and/or Medical Necessity.

Commercial Payer Polcies

View Clinical Indications for Medical necessity on procedures, Suggested Code Selection, and Documentation Requirements.

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AHA Coding Clinic® ICD9/10 & HCPCS

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PDGs- Provider Documentation Guides

PDGs- Provider Documentation Guides

General Links and Resources

Medicare Provider Compliance

Medicare Quarterly Provider Compliance Newsletter

Standard Documentation Requirements

Standard Documentation Requirements for All Claims Submitted to DME MACs

Documentation of Medical Necessity

Documentation and Coding that Demonstrates Medical Necessity

Compliance with Documentation Requirements

Complying with Medical Record Documentation Requirements

Signature Requirement Q&A's

Signature Requirement Questions and Answers

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CDI

Clinical Documentation Improvement

Select the title to see a summary and a link to the full article.

Medicare Improper Payment Report — Chiropractic 2019 to 2021

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

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

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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.

Preventive Services

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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...

Critical Care Services Changes in the Medicare 2022 Final Rule

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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.

Watch out for New ICD-10-CM Codes

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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

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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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