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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.

The New ICD-10-CM Code Updates Are Here — Are You Ready?

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Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...

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Q/A: What if my Patient Refuses to Fill out the Outcome Assessment Questionnaire?

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Question: What if my Medicare patient refuses to fill out the outcome assessment questionnaire? Answer: Inform the patient that Medicare requires that you demonstrate functional improvement in order for them to determine if the care is medically necessary. In other words, they may have to pay for the care out of pocket if ...

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Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?

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Question: What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms. Answer: There is no question that these adjustments would be considered ...

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The Importance of Medical Necessity

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ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...

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2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done

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The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...

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What Medical Necessity Tools Does Find-A-Code Offer?

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Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

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How to Code Ophthalmologic Services Accurately

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Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code. According to Article A19881 which was published in 2004 and ...

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Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

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Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?

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Electrical Stimulation and Electromagnetic Therapy Devices

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Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.

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Q/A: If Orthopedic Tests are Negative, do You List Them in Your Treatment Notes?

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Question: If orthopedic tests are negative, do you need to still list them in your treatment notes? Answer: Yes. Any tests which are performed by a healthcare provider, regardless of the result, should be documented in the patient record. This record is the only way that a reviewer or another provider ...

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Let's Talk High Risk E/M Services

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Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.   Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...

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What is Medical Necessity and How Does Documentation Support It?

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We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

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Auditing Chiropractic Services

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Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.

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The Impact of Medical Necessity on High Level E/M Services

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I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"  The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

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Understanding NCCI Edits

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Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

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Coding Medicare Initial Preventive Physical Exams (IPPE)

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The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...

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Medical Necessity vs. Documentation for Inpatient Services

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Auditing the documentation of inpatient and observation E/M services can often be challenging. Many of the notes we are provided for review include so much information that the note feels like a short novel instead of documentation for one date of service. This over-documentation can make it difficult to see ...

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How to Report Co-Surgeons Using Modifier 62

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Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...

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Home Oxygen Therapy

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Home Oxygen Therapy Guidelines

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Keeping Up to Date

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Keeping up to date on coding and documentation changes, is critical for medical coders, billers, auditors, and compliance personnel. Every year American Medical Association (AMA) creates, revises, and deletes CPT codes on January 1st. Same thing occurs with the ICD-10 codes in October. For CPT codes, the intention of the...

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Auditing looking between the lines

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When given the task of auditing a group of charts, most often the scope of the audit is well defined. For me, there are times when my natural inquisitive nature turns on and I find my noticing the "timing" of parts of documentation. These are things that you would not...

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Medi-Cal Coverage Criteria for Hospital Beds and Accessories

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Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.

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Documentation Requirements for Allergy Testing 10/29/2018

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Per CMS, First Coast Service Options LCD 33261: Medical record documentation (e.g., history & physical, office/progress notes, procedure report, test results) must include the following information, and be available upon request: A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient. The medical necessity for performing ...

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We've Always Done It This Way and Other Challenges in Education

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As coders, auditors, and compliance professionals, we are the provider's advocates in closing the gap between what is medically necessary and what is required for documentation. Sometimes that places us in the role where we need to save our clinicians from themselves, and the patterns they have fallen into...

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Medicare Timed Codes Guidelines

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Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time. It should be noted that while ...

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When Medical Necessity and Medical Decision Making Don't Match

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As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...

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Patients Over Paperwork?! We have Great News!

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Spend more time with patients and less time documenting? Great Concept! Document meaningful information? Sound good? CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...

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Documentation: Face to Face for Home Health Certification

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As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care. Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The ...

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WHO Said ICD-11 is Coming Soon

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Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...

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Home Oxygen Therapy -- CMN for Oxygen

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The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.

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Key Performance Indicators Revisited

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DI's present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness and effectiveness of medical record documentation. Common KPIs include number of physician queries left, number of queries responded to by the physician, number of queries responded to...

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Brooklyn Chiropractor OIG Report - Lessons Learned

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In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid. Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation. Read here to learn more.

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Critical Care Documentation

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Critical care documentation should show critical need for the patient AND immediate action by the provider....

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Proper Record Keeping and Documentation

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Proper record keeping and documentation is not only essential for today’s dental practitioner, but is also required by law. Moreover, correct, current and accurate records directly enhance patient care by enabling the dentist to plan treatments, monitor progress, and provide essential notations. Clear and concise treatment plans, medical alerts, and ...

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Home Oxygen Therapy -- A Face-to-Face Encounter

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What is required for a Home Oxygen Therapy, Face-to-Face Encounter.

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Documentation for Evaluation and Management (E/M) Services

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According to WPS, when billing or coding for E/M services you should follow a few guidelines. Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation. Critical Care Visits  Clear indication of patient ...

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Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?

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In order to understand and answer the question, "Why code 99080 is being denied when billed with an E/M Service, it is important to first review the requriements of selecting the appropriate level of Evaluation and Management service and how that relates to reporting a 99080 special report service. Continue reading for better understanding.

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When is 97112 Neuromuscular Re-education Billable?

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Q: I just received a note from an attorney regarding a patient who was rear ended about 40 mph and ended up with neuropathy in her upper and lower extremities. We treated her for about 3 months after previous care failed to give much relief. I used flexion distraction and deep muscle stimulation to break up adhesions from the injury and used the 97112 code of neuromuscular re-education. The insurance company said that code was not warranted for her spinal sprain diagnosis and denied all of the services. Do you know how I could justify it? It greatly improved her condition with each visit and the patient said we provided the greatest relief she received.

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The Comprehensive Error Rate Testing Program

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With nearly a million physicians in this country, how do auditing organizations determine whom to audit?

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Documentation for Ordering Oxygen Supplies and Equipment

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The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment.

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Documentation for Negative Pressure Wound Therapy

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The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.

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Documentation for Surgical Dressings

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The Medicare Learning Network provides guidance on required documentation for surgical dressings.

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Documentation for Enteral Nutrition

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The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...

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Documentation for Home Blood Glucose Monitors (BGM)

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The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...

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Documentation for Therapeutic CGMs and Related Supplies

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The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies

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Documentation for Manual Wheelchairs

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The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases....

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Documentation for Lower Limb Prosthesis

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The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them: For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation. For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...

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Documentation for Bacterial Culture Lab Tests

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The Medicare Learning Network provides guidance on how to prevent denials of Bacterial Culture Laboratory Tests

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Documentation for Bacterial Culture Lab Orders

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The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests...

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Documentation for Power Tilt/Recline Seating Systems for Wheelchairs

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The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems...

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Documentation for Ostomy Supplies

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The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....

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Documentation for Home Health Services (Part A non DRG)

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The Medical Learning Network provides coverage guidance, which should be documented, for home health services.

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Documentation and Orders for Respiratory Assistive Device

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The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.

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Documentation and Orders for Laboratory Tests

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The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.

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Documentation for Skilled Nursing Facilities

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The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).

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Documentation for Inpatient Rehabilitation Facilities

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The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).

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Telemedicine Billing and Reimbursement

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The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding ...

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The Coder as the Last, Best Hope for the Right DRG

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f the story doesn't make sense, there is probably something missing. There are a variety of reasons why the DRG might not tell the story of the patient encounter....

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Pre-Existing or Gestational?

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It is important to make a clear distinction between pre-existing conditions and conditions brought on by the pregnancy (gestational) or pregnancy related conditions. Condition Detail: Was the condition pre-existing (i.e., present before pregnancy)? Trimester: When did the pregnancy-related condition develop? Casual Relationship: Establish the relationship between the pregnancy and the complication (e.g., preeclampsia) Code examples: O99.011 Anemia ...

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Traumatic Subluxation Coding Controversy

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There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on ...

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Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5B

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Documentation Modifiers direct prompt and correct payment of the anesthesia claims submitted. Documentation modifiers (AA, QK, AD, QY, QX and QZ) must be billed in the first modifier field. If a QS modifier applies, it must be in the second modifier field. Processing delays and denials may occur for claims submitted ...

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Creating a Culture of Compliance in 2018

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This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....

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Better Office Communication Leads to Stronger RCM

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According to a recent Physicians Practice study, one of the top five reasons for denied medical claims is a lack of adequate documentation. While this might seem like an electronic records issue, the problem may be bigger than that. ...

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NEW on Find-A-Code...National Coverage Determinations (NCDs)

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Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...

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Antiresorptive Osteonecrosis of the Jaws

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Osteonecrosis is a serious bone disease caused when the bone is starved of its normal blood supply. Because bone is living tissue, without a good supply of oxygenated blood, it becomes weakened and then dies. Scientists have not been able to identify the exact cause of osteonecrosis of the jaws, but they have ...

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GeneSight Psychotropic Testing and Documentation

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According to Wisconsin Physicians Service Insurance Corporation, there is limited coverage for the GeneSight® Psychotropic (AssureRx Health, Inc, Mason, OH) gene panel. GeneSight® testing may only be ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) (in accordance with DSM IV/V criteria) who are suffering with refractory moderate to ...

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Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive

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According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria: Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing. Morning stiffness of less than 30 minutes in duration or crepitus on motion of the ...

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Reimbursement for Therapy Students

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According to CGS Administrators, qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision ...

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Proper Usage of Electrical Stimulation

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According to CGS Administrators, most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment. 97032 is a constant attendance electrical stimulation modality ...

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Skilled Therapy, When it's Appropriate and Billable

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According to CGS Administrators, "A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, ...

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Initial Evaluation Codes for PT's and OT's

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According to CGS Administrators, for initial evaluations, PTs shall use code 97161-97163 and OTs shall use code 97164-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation. These evaluation codes are untimed, billable as one unit. Do ...

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PT and OT Reevaluation Coding

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According to CGS Administrators, the reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.Reevaluations are distinct from therapy ...

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General Physical Therapy Modality Guidelines

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According to CGS Administrators, CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention. CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes ...

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Diathermy eg Microwave Use and Documentation

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According to CGS Administrators, the objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema.Diathermy achieves ...

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Ultrasound Therapy

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According to CGS Administrators, therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone may receive ...

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Hydrotherapy Guidelines

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According to CGS Administrators, hydrotherapy involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of ...

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Modifiers 54-55, split surgical and postoperative care

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54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care 55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care Modifiers should be placed on the surgical code Used on 10 day and 90 day surgical procedures Both the surgeon and the physician providing the postoperative ...

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

November 5, 2019: Proving Medical Necessity and Functional Improvement

Topic and description coming soon!

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May 14th, 2019: Confusing Codes for Chiropractors - 97110 versus 97112 versus 97530

In this webinar, you'll get a deep dive into three therapeutic procedure codes. Dr. Gwilliam, a chiropractor and certified professional coder, will take you thorough the ins and outs of therapeutic exercises, activities, and neuromuscular reeducation. They will be compared and contrasted with examples to make sure everyone leaves with the confidence to document and bill them correctly.

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Chiropractic Manipulative Treatment (CMT) Coding and Documentation (Part 1)

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.

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Documenting Diagnoses Like a Peer Reviewer (Part 2)

Chiropractors only use a fraction of the codes available in the ICD-10 code set. But each group of diagnoses have things to teach us based on coding guidelines, objective findings, standards of care, and more. In this presentation Dr. Gwilliam will review the most commonly used diagnoses (by chiros) and make sure you know everything that should be documented in order for a peer reviewer to walk away satisfied.

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Documenting Treatment Plan and Goals That Actually WORK - November 20th, 2018

Dr. Friedman will discuss the need to document Treatment Plan and Goals and what we MUST document and what we SHOULD document. He'll also demonstrate how we can do this in the least amount of time and with the least amount of effort.

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Medicare Reviews

Medicare continues to increase their efforts to review doctors and recover “overpayments”. This increases the likelihood that your notes will be reviewed and that you will be required to pay money back to Medicare. In this webinar Dr. Short will show you:  Why you should appeal every adverse decision.  How to appeal adverse decisions.  What information you need in your documentation for an effective appeal.  How to structure your appeals to be most effective.

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Documenting Diagnoses Like Peer Reviewer (Part 1)

When an outsider looks at your records, you want them to easily find exactly what they are looking for. Let ICD-10 codes guide you as you choose the words to use in the Diagnostic Statement in your initial encounter. Don't assume a reviewer can interpret your clinical findings. Spell it out for them. Dr. Gwilliam, ICD-10 guru and all around good guy, will show you how to do that is this webinar.

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X-Ray and the Evidenced Based Practice: How DC’s Can Demonstrate the Need for X-Rays

Learn: Improve Patient Outcomes and Satisfaction with X-Rays Increase Practice Profits Using Research Studies Incorporate Biomechanical Measurements in Your Patient Communications

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Neuromuscular Reeducation, Massage Therapy - Proper Use, Documentation and Coding

In this webinar, Dr. Howard Levinson (Forensic Consultant) will address the erroneous use and billing of Neuromuscular Reeducation, Massage Therapy and Hydrotherapy in chiropractic clinics. He will offer strategies regarding how these services may be used appropriately in the chiropractic setting and provide documentation and coding information.

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Pain in the Ass*essment

In this webinar, Dr. Friedman will discuss how the Assessment may be the most misunderstood aspect of our documentation and how we can document it properly and quickly so it shows how the patient is progressing with care.

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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.

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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.

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The KEY to EXCEPTIONAL Documentation in the LEAST Amount of Time

Dr. Friedman has been practicing for 31 years and has been teaching documentation, performing record reviews and IMEs and helping doctors with board issues and malpractice complaints for years. With all of this experience in the documentation world, Dr. Friedman has discovered the one common denominator that can help us document exceptionally well in much less time. This one common denominator, if documented properly, will work for every kind of patient, including Medicare and personal injury. This ONE thing might just be the key to unlocking the treasure.

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Coding and Auditing Wound Care

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.

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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.

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Improve your Over-the-Counter Collections NOW

In this webinar, we're going to go back to the fundamentals and allow you to evaluate your own over-the-counter collections systems and immediately implement one or more steps for improvement, making a difference in your cash flow, starting now.

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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.

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Coding and Documenting Physical Therapy Treatment Modalities

Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA May 22nd, 2018 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET Ever wonder how to get paid for that e-stim or ultrasound? Do payers give you a hard time and ...

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How to Handle High Deductibles, Cash Plans and Pre-Pays

In this webinar, Dr. Marty Kotlar (certified coding and compliance expert) will discuss how to handle high deductibles, pre-pays, discounts, hardships and in-network vs. out-of- network care plans. Learn what the OIG is looking for when it comes to discounts and offering free services.

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Proving Medical Necessity and Functional Improvement

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. You will learn: -What is Medicare’s definition of medical necessity. -What does Medicare’s determination of Medical Necessity mean to your care plan. -How to prove medical necessity. -How to report this information to Medicare. -How to determine Maximum Medical Improvement.

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Documenting Diagnoses Like a Peer Reviewer, Take 2

In his last ChiroCode Webinar, Dr. Gwilliam went over the details of three conditions that are covered by the Diagnosis and Documentation cards available in the ChiroCode store. By popular demand, Dr. Gwilliam has agreed to come back and cover three more. The goal is to show you how to ensure that the code you select matches the documentation created at the encounter. You don’t need to research all of the guidelines for each code in the ICD-10 Tabular List. It has already been done for you. You’ll find out which objective tests to perform and even which CPT codes make the most sense to link to the diagnoses you pick. If you can’t wait for the presentation, pick up your copy of the cards from ChiroCode.com/store today!

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Coding and Auditing TeleHealth Services

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.

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Documenting a Great Patient History in Much Less Time

We've all been taught how critical a great history is for our new patients, but many chiropractors are skipping important steps in an effort to save time. Dr. Friedman will explain what we need to document and how to get all the information in the least amount of time without missing anything. He will also discuss how by documenting the history properly on the first visit, all subsequent visits can be documented easier and faster.

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Coding Auditing Inpatient Evaluation and Management — A Hands-On Experience

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.

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Documenting Diagnoses Like a Peer Reviewer

The right ICD-10 code is the one that matches the documentation. Does your record clearly distinguish between sciatica and radiculopathy? Do you know which codes are excluded from being billed alongside myositis? You will leave this presentation with a clear understanding of what to document for the diagnoses you use most, and match it to the CPT code that makes the most sense. Dr. Gwilliam, a certified auditor and ICD-10 Instructor will show you the way.

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The ABN 2018

The Advanced Beneficiary Notice of Non-coverage is one of the most important Medicare forms that you can use in your office because it protects your right to be paid. Dr. Ron Short will show you how, when and why to use the ABN and how to properly complete the form.

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Trauma and the Presence of Effusion or Edema

How do you document them? What PI codes do you use to report them? What PI codes do you use to validate them? Can they both be present at the same time? How do you treat them? As a Med-Legal Consultant & Strategist, Chiropractor, PI Practice Coach, Speaker, Author, Inventor, Educator and entrepreneur, Dr. Grant’s mission is to help professionals gain greater confidence, skill, & strength to successfully deliver the best recovery care and provide powerful claim strategies for traumatically injured patients.

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Surgical Coding and Auditing

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.

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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: General Multi-SystemCMS-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: PsychiatryCMS-Novitas Solutions: Specialty Exam: RespiratoryCoding and Billing WorkshopsCoding_Changes_2014CR 5550 Clarification - Signature Requirements by CMSDetails about EHR Incentive ProgramDocumentation Topics PageEHR Topics PageGastro_ArticleGeriatricHHS, 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 LimitsMedlinePlusNoridian Documentation ChecklistsNoridian Review of A5500 (Therapeutic Shoes)OIG Issues Renewed Focus on Chiropractic ServicesPressure Ulcer GuidelinesProperly Appealing CCI Edit Denials - by ACAQuality 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 CareThe Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 BThe One-Minute Spinal Outcome Measure


Reimbursement Guides
2020 Edition

Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.

  • Medicare
  • Procedure & Supply codes
  • Documentation
  • Compliance
  • HCC information
  • ICD-10-CM codes



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