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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GERD: Improving the Coding, Documentation, Billing, and Reimbursement Flow

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.

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.

Leveraging Hierarchical Condition Category (HCC) Coding to Improve Overall Healthcare

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.

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.

Identifying the MEAT to Support Reporting Chronic Conditions in the Computer-Assisted-Coding (CAC) World

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?

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.

Understanding the Changes to the 2023 Evaluation & Management (E/M) Definitions for Chronic Conditions

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.

Four Ways Your Organization Can Benefit from Gathering and Reporting Social Determinants of Health Data

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.

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.

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 ...

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,...

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.

CMS Started to Enforce Applicable Price Transparency Requirements

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.

Medicare Advantage and Part D Advance Notice Addresses Health Equity Initiatives Slated for 2023

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.

Billing and Documenting for Therapeutic Exercises versus Therapeutic Activities


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:

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.

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 . . .

Do You Know What Code is Used to Report Long-Haul COVID-19 Conditions?

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?

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

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.

CMS Claims Risk Adjustment Overpayments Commonly Include 10 Specific Diseases

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.
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Select the title to see a summary and a link to the full webinar information.  some webinars require a subscription to view.

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.

Dealing with the Little Coding Conundrums 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coding 2022 Care Management Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Do Minor Procedures Feel like Major Work? 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Reporting Telemedicine Services by Aimee Wilcox 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

What do Chiropractors Need to do to Comply with the No Surprises Act? 


Chiropractic Documentation: The Subjective Element 

by  Ron Short, DC MCS-P CPC

Chiropractic Documentation: The S.O.A.P. Format and Additional Information 

by  Ron Short, DC MCS-P CPC

Chiropractic Manipulative Treatment: Coding and Documentation 


Chiropractic Treatment Paradigm 2021 

by  Ron Short, DC MCS-P CPC

New Dental Codes for 2021 and Find-A-Code Dental Tools/Resources 

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.

Dental Medical Billing & Coding Certification on - Your Dental Certification Destination 

by  Christine Taxin, President - Links2Success  and  LaMont J. Leavitt, CEO - innoviHealth is the industry leader for dental coding and billing certifications. The credentialing exams are hosted and administered by 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.

Rock Solid Care Plans 


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.

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.

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.

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.

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.

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

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.

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.

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