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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Clinical Documentation Improvement

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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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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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