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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Documentation of Medical Necessity
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May 5th, 2020
ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting
Published May 5th, 2020|
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 - ...
April 21st, 2020
Special COVID Laboratory Specimen Coding Information
Published April 21st, 2020|
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.
April 20th, 2020
Dismal OIG Report on Telemedicine
Published April 20th, 2020|
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.
October 1st, 2019
The New ICD-10-CM Code Updates Are Here — Are You Ready?
Published October 1st, 2019|
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: ...
August 6th, 2019
Q/A: What if my Patient Refuses to Fill out the Outcome Assessment Questionnaire?
Published August 6th, 2019|
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 ...
July 22nd, 2019
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
Published July 22nd, 2019|
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 ...
July 9th, 2019
The Importance of Medical Necessity
Published July 9th, 2019|
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 ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
Published June 13th, 2019|
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 ...
June 6th, 2019
How to Code Ophthalmologic Services Accurately
Published June 6th, 2019 - Last Review/Update June 11th, 2019|
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 ...
May 13th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices
Published May 13th, 2019 - Last Review/Update May 20th, 2019|
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.
May 6th, 2019
Q/A: If Orthopedic Tests are Negative, do You List Them in Your Treatment Notes?
Published May 6th, 2019|
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 ...
April 23rd, 2019
Let's Talk High Risk E/M Services
Published April 23rd, 2019|
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 ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
Published April 23rd, 2019|
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 ...
April 22nd, 2019
Auditing Chiropractic Services
Published April 22nd, 2019|
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.
March 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
Published March 21st, 2019|
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. ...
March 1st, 2019
Understanding NCCI Edits
Published March 1st, 2019|
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 ...
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
Published February 12th, 2019|
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 ...
January 25th, 2019
Medical Necessity vs. Documentation for Inpatient Services
Published January 25th, 2019 - Last Review/Update January 29th, 2019|
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 ...
January 22nd, 2019
Home Oxygen Therapy
Published January 22nd, 2019|
Home Oxygen Therapy Guidelines
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November 5th, 2019
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.
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.
December 18th, 2018
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.
December 4th, 2018
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.
November 6th, 2018
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.
October 16th, 2018
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.
October 2nd, 2018
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
September 25th, 2018
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.
September 18th, 2018
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.
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.
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.
July 17th, 2018
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.
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.
June 5th, 2018
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.
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.
May 22nd, 2018
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 ...
May 8th, 2018
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.
May 1st, 2018
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.
April 17th, 2018
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!
February 22nd, 2018
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.
January 25th, 2018
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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