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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Select the title to see a summary and a link to the full article. some articles require a subscription to view.
by Jessica Hocker, CPC, CPB, CRC
GERD is a common condition where stomach acid flows back into the esophagus, causing symptoms like heartburn. It is treated with lifestyle changes, medication and surgery. Proper documentation is important for accurate coding and treatment. Providers should stay up-to-date with coding and billing policies.
Dec 27th, 2022
Compliance Billing: Power Mobility Devices
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.
by Kem Tolliver, CMPE, CPC, CMOM
Diagnosis code usage is a major component of optimizing HCCs to improve overall healthcare. Readers will gain insight into how accurate diagnosis code usage and selection impacts reimbursement and overall healthcare.
Dec 20th, 2022
Accurately Reporting Diabetic Medication Use in 2023
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Along with the ICD-10-CM coding updates, effective as of October 1st, the guidelines were also updated to provide additional information on reporting diabetic medications in both the general diabetic population and pregnant diabetics. Accurate reporting is vital to ensure not only maximum funding for risk adjusted health plans, but also to ensure medical necessity for the services provided to this patient population.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The benefits of computer-assisted-coding (CAC) are great and understanding how to engage with the engine to ensure maximum coding efficiency is vital to the program's success for your organization. But how do you know when to accept an autosuggested code and when to ignore it, especially when it has to do with historical patient data?
Nov 22nd, 2022
Fatten Up Your BMI Coding Skills
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Accurately reporting body mass index (BMI) codes has become important with many of the payers reimbursing provider organizations up to ten dollars per chart for reporting 3008F with a documented BMI code. However, as is almost always the case, it isn't a simple scenario of collecting, documenting, and reporting the patient's BMI but rather hitting the mark on all of the criteria that goes along with it and understanding how to identify morbid obesity based on coding guidelines in the ICD-10-CM code set and specific payer policies.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
This will be the third time since 2021 that the diagnosis complexity definitions have undergone significant changes. The initial 2021 changes were specific to Office and Other Outpatient E/M services and due to some confusion surrounding a few of the guidelines, updates to them were published by the AMA in April of 2021 with an effective date of January 1st. Because the 2023 E/M changes are more focused on the remaining E/M categories, especially in the hospital facility, new definitions were added and old definitions changed.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Providers who actively engage in collecting and reporting social determinants of health (SDoH) open avenues of identifying and treating their patients' population health trends. Pairing chronic conditions that are difficult to control with identified SDoH circumstances such as transportation or electricity insecurity, can help identify those patients who may wish to be healthier, but who are dealing with circumstances that prevent compliance, such as transportation or access to electricity, for instance.
Oct 24th, 2022
2023 Evaluation & Management Updates Free Webinar
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Oct 20th, 2022
Billing for Incontinence and Urinary Products
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
We all understand anything covered under health insurance must be medically necessary. In other words, it must be essential in treating and managing a patient's condition or to evaluate, diagnose, or treat an illness, injury, disease, or its symptoms. In this article, we will address catheters, urological supplies, and disposable ...
Oct 11th, 2022
AHIMA Releases New Guidelines for Queries
by Chuck Buck
The updated guidelines were developed jointly by AHIMA and ACDIS. The American Health Information Management Association (AHIMA), in collaboration with Simplify Compliance’s Association of Clinical Documentation Integrity Specialists (ACDIS), jointly announced a highly anticipated preliminary update to their Guidelines to Achieving a Compliant Query Practice on October 10,...
Sep 8th, 2022
Are You Prepared to Avoid Repayments
by Raquel Shumway
Watchful care is needed when submitting claims.
The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.
by Amanda Ballif
Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The current Administration constantly talks about health equity initiatives but what exactly does that mean for our providers and medical practices? Centers for Medicare and Medicaid Services (CMS) has published the 2023 Medicare Advantage and Part D Advance Noticed with significant focus on their definition of health equity and what is means to promote it within our individual practices and among health payer plans.
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Chiropractors treat, among other things, issues with the musculoskeletal system. Active therapeutic procedures are accepted as effective ways to treat many common conditions and therefore can be billed and generate revenue for a clinic. Two common CPT codes that might be used in a chiropractic setting include:
Jul 7th, 2022
New Audio-Only Telehealth Guidance to Meet HIPAA Rules
by U.S. Department of Health & Human Services
Covered entities (healthcare providers and health plans) can use remote communications, called telehealth, to provide services to patients as long as they follow certain guidelines. Because certain populations may have difficulty using audio-video telehealth, HHS is now issuing this guidance on audio-only telehealth. This guidance will help ensure that individuals can continue to benefit from audio-only telehealth by clarifying how covered entities can provide telehealth services and improve public confidence that covered entities are protecting the privacy and security of patients' health information.
Jun 8th, 2022
Medicare Improper Payment Report (2021)
by Raquel Shumway
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 . . .
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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.
Select the title to see a summary and a link to the full webinar information. some webinars require a subscription to view.
Jan 12th, 2023
2023 Annual Update Summary
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Be sure you are ready for 2023 with this review of the upcoming coding and reimbursement updates for 2023. This informative webinar discusses changes to CPT codes and guidelines including a summary of the changes to E/M services and an overview of changes to other CPT categories.Jul 7th, 2022
Dealing with the Little Coding Conundrums
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jun 2nd, 2022
Coding 2022 Care Management Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May 5th, 2022
Do Minor Procedures Feel like Major Work?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 14th, 2022
Reporting Telemedicine Services by Aimee Wilcox
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Jan 11th, 2022
Chiropractic Documentation: The Subjective Element
by Ron Short, DC MCS-P CPC
by Ron Short, DC MCS-P CPC
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Jul 6th, 2021
Chiropractic Treatment Paradigm 2021
by Ron Short, DC MCS-P CPC
by Christine Taxin, President - Links2Success
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.Jan 21st, 2021
Dental Medical Billing & Coding Certification on QPro.com - Your Dental Certification Destination
by Christine Taxin, President - Links2Success and LaMont J. Leavitt, CEO - innoviHealth
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.Jan 7th, 2020
Rock Solid Care Plans
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
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.Nov 5th, 2019
Proving Medical Necessity and Functional Improvement
by Ron Short, DC MCS-P CPC
Medicare is required by law to pay for care that is medically necessary. Medicare considers functional improvement to be the primary indicator of medical necessity for chiropractic care. It is up to you, the doctor, to prove functional improvement and medical necessity with your documentation. Dr. Short will show you how to use common practice tools to document functional improvement, medical necessity and maximum medical improvement.by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
The most used codes in chiropractic are 98940, 98941, 98942, and 98943. In this webinar, Dr. Gwilliam will go over the fundamentals of these codes and make sure you are proficient with them. They probably play a bigger part of your practice than any other code, so it is worth it to make sure you are reporting them correctly. By the end of this presentation you will be able to diagnose, document, and code properly for CMT, as well as avoid common mistakes.Jul 6th, 2018
Coding and Auditing Wound Care
by Find-A-Code™
In this webinar, Aimee will review wound care coding and auditing information for wound care services, including proper modifier use, NCCI edits, Medicare coverage guidelines, and documentation requirements.Mar 29th, 2018
Coding and Auditing TeleHealth Services
by Find-A-Code™
Do you report or audit Telemedicine services now or are you considering offering them? Come and learn more about the rules and guidelines surrounding Telehealth services including, documentation requirements, eligible CPT and HCPCS Level II codes, modifiers, and the newest updates to Medicare Telehealth policies.by Find-A-Code™
Do your providers perform and report Evaluation and Management (E/M) services in the inpatient setting? Does the documentation match with the services being billed, or does it fall short? Join Aimee for a hands-on audit of an inpatient E/M service and get an idea of the information and documentation needed to correctly code inpatient E/M services.Jan 25th, 2018
Surgical Coding and Auditing
by Find-A-Code™
Ever wonder what an auditor is looking for when they review your surgical coding? Join Aimee and review the basic rules and documentation requirements. We’ll tear apart a couple of operative reports, code them, review NCCI edits, modifiers, and more. Get an idea of how you are doing and things you may want to incorporate into your practice to be better prepared when an audit comes your way. Also, we’ll review our cool Code-A-Note tool and how it can help you locate CPT and ICD-10-CM codes quickly. This tool is great for new coders, coders new to a specialty, difficult coding situations, or anyone who just wants a second opinion on their code options.Links and resources by topic.
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