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.
Select the title to see a summary and a link to the full article.
May 5th, 2020
ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | 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 - ...
Special COVID Laboratory Specimen Coding Information
By Wyn Staheli, Director of Research | 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.
By Wyn Staheli, Director of Research | 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.
The New ICD-10-CM Code Updates Are Here — Are You Ready?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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: ...
Q/A: What if my Patient Refuses to Fill out the Outcome Assessment Questionnaire?
By ChiroCode | 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 ...
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
By Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA | 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 ...
By Marge McQuade, CMSCS, CHCI, CPOM | 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 ...
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | 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.
Q/A: If Orthopedic Tests are Negative, do You List Them in Your Treatment Notes?
By Wyn Staheli, Director of Research | 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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com | 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.
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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. ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | 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 ...
Medical Necessity vs. Documentation for Inpatient Services
By NAMAS | 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 ...
By NAMAS | Published December 7th, 2018 - Last Review/Update December 20th, 2018
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...
By BC Advantage | Published November 30th, 2018 - Last Review/Update January 9th, 2019
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...
Documentation Requirements for Allergy Testing 10/29/2018
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 30th, 2018
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 ...
We've Always Done It This Way and Other Challenges in Education
By BC Advantage | Published October 19th, 2018 - Last Review/Update November 1st, 2018
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...
When Medical Necessity and Medical Decision Making Don't Match
By BC Advantage | Published August 3rd, 2018 - Last Review/Update September 24th, 2018
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...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 18th, 2018
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 ...
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 9th, 2018
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 26th, 2018
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 ...
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.
By Glenn Krauss | Published May 16th, 2018 - Last Review/Update May 24th, 2018
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...
By Wyn Staheli, ChiroCode Director of Research & Dr. Evan Gwilliam, Clinical Director PayDC Software | Published April 23rd, 2018 - Last Review/Update February 28th, 2019
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.
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 ...
Documentation for Evaluation and Management (E/M) Services
By | Published March 26th, 2018
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 ...
Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?
By Wyn Staheli, Director of Research | Published March 21st, 2018 - Last Review/Update January 30th, 2019
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.
When is 97112 Neuromuscular Re-education Billable?
By Dr. Evan Gwilliam, VP for PayDC | Published March 13th, 2018 - Last Review/Update January 31st, 2019
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.
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
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 ...
The Coder as the Last, Best Hope for the Right DRG
By Dr. Erica Remer | Published February 12th, 2018 - Last Review/Update April 12th, 2018
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....
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2018
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 ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
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 ...
By Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC | Published January 26th, 2018 - Last Review/Update February 7th, 2018
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....
By Ashley Choate | Published January 24th, 2018 - Last Review/Update March 29th, 2018
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. ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
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. ...
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 ...
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 ...
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Find-A-Code | Published January 9th, 2018
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
Modifiers 54-55, split surgical and postoperative care
By Find-A-Code | Published January 4th, 2018
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 12th, 2017
The exact level of the subluxation must be specified in the documentation to substantiate payment of a claim.
You may document the exact bones such as C3, C3 or the area if it implies only certain bones such as the Occipito-atlantal - Occiput, and C1 (Atlas).
C1 is the first vertebra known as the atlas. The axis-form is ...
By Wyn Staheli, Director of Research | Published November 30th, 2017 - Last Review/Update February 5th, 2019
Q: In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?
Speech-Language Pathology Services Policy from UniCare
By Find-A-Code | Published October 27th, 2017
Medically Necessary:
Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
Based on a plan of care, the therapy sessions achieve a specific ...
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published October 20th, 2017 - Last Review/Update January 31st, 2018
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
Acronyms and Abbreviations: When You Fall into the Grey Area
By Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC | Published October 6th, 2017 - Last Review/Update February 1st, 2018
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....
Clarification to "The Big Myth: If it Isn’t Written, it Wasn’t Done"
By David Glaser | Published October 6th, 2017
Several months ago we ran an article titled, The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims, written by David M. Glaser, which resulted in a request for clarification from some of our readers.
One question posed, was “Who exactly is Mr. ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 15th, 2017 - Last Review/Update January 31st, 2018
Have you looked for published guidance on cloning/copying and pasting from the Centers for Medicare & Medicaid Services (CMS)? There is one published resource that provides rudimentary guidance.....
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
Focus on Clinical Documentation to Improve Coding and Audit Results
By Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP | Published June 29th, 2017
Auditors spend their day surrounded by the end product of the health care process. Those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 13th, 2017 - Last Review/Update July 26th, 2017
Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:
Paint a picture of the patient’s impairments and ...
By Dr Evan Gwilliam | Published May 22nd, 2017 - Last Review/Update January 31st, 2019
What is required for documenting a maintenance visit for a Medicare beneficiary?
Watch this video by Dr. Evan Gwilliam for his thoughts.
ChiroCodeQ&A_maintenance visit from Innoventrum on Vimeo.
ChiroCode Q&A "Maintenance Visit Documentation" With Dr. Evan Gwilliam. https://vimeo.com/208521720
...
By ChiroCode | Published April 28th, 2017 - Last Review/Update January 31st, 2019
Q: An insurer told me that chiropractors cannot bill 99204 or 99214 because those exams "require a level of decision making that would typically only occur in an emergency room." Is this true? Do I have any recourse?
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 20th, 2017 - Last Review/Update July 28th, 2017
The Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services describes the coverage limits of outpatient physical and occupational therapy services under Medicare Part B. It's billed to either the Medicare Fiscal Intermediary (FI) or Part A or Medicare Carrier or Part B MAC when services are provided ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
When the medical documentation submitted is inadequate to support payment for the services billed, it may be determined that the claim contained insufficient documentation. If the claims reviewer is unable to conclude the services, some or all, were actually provided, they may determine the claim is unprocessable or incomplete. There are ...
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 27th, 2017 - Last Review/Update August 16th, 2017
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. ...
By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP | Published January 23rd, 2017 - Last Review/Update February 8th, 2019
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 20th, 2017 - Last Review/Update August 2nd, 2017
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 ...
By ChiroCode | Published January 13th, 2017 - Last Review/Update January 31st, 2019
Whiplash Damages in Rear-end Collisions - The Patient’s Dilemma:
The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it.
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
How soon after a visit must the documentation be complete?
By | Published July 29th, 2016
Most physicians, Nurse Practitioners and Physician Assistants document the service they have performed on the same calendar date. Occasionally, at the end of the day, the service might not be documented before the clinician leaves the office, particularly if called away urgently. In that case, the service is documented...
Can’t we bill a low level E/M with every procedure? No! Medicare says this: Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a...
One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.” Put more specifically, the OIG reports that Medicare Administrative Contractors (MACs) have seen an increase in...
What is the difference between the two sets of Guidelines? There are two major differences. The first is in the history of the present illness (HPI). In the 1995 Guidelines, in order to document a history of the present illness at a detailed level, the clinician must document four elements...
Understanding and Using Taxonomy Codes to Maximize Reimbursement
By | Published June 9th, 2016
Taxonomy codes are used by insurers as indicators of legal scope of practice. Scope of practice is key to getting reimbursed under the Affordable Care Act or ObamaCare. However, Most providers will only choose one taxonomy code to describe their training. This limits their scope of practice. To maximize scope ...
Medicare does not permit a physician practice to bill for family meetings without the patient present. The physician may not bill Medicare, nor may they bill the family member. It is fairly common for the spouse or child of a patient to ask to see the...
Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures...
Chief Complaint - Rules related to the Chief Complaint in the D.G.
By | Published December 2nd, 2015
The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the...
Past medical, family and social history - Documenting and auditing the history section of an E/M service
By | Published December 2nd, 2015
When an Evaluation and Management service requires past medical, family and social history, (or one or two of those) here is what needs to be documented, and the rules around using one that is previously documented. Past medical history includes the patient's chronic illnesses, previous...
History of the present illness - HPI Rules from the Documentation Guidelines
By | Published December 2nd, 2015
Here are the elements of the HPI: Location: Where do the patient's symptoms occur? In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur. Head, shoulders, knees...
CMS clarifies the ways physician practices can respond to additional documentation requests
By | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
The Joy of Medicine - AMA wants to Restore the Joy of Medicine
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 1st, 2015
The AMA is investing in making happier doctors and believes it will help them delver better care. Physicians have been put under tremendous stress with government oversights and insurance companies, medical decisions are bound to be compromised. Frustration becomes even more apparent with trying to get approval for treatment and ...
You do not need to change or rewrite your original orders
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
The Documentation Guidelines say social history is: an age appropriate review of past and current activities. As auditors, we interpret this to include: smoking, alcohol and drug use living arrangements employment history school history support system, if relevant In order to credit social history in a...
What is the difference between the two sets of Guidelines?
There are two major differences. The first is in the history of the present illness (HPI). In the 1995 Guidelines, in order to document a history of the present illness at a detailed level, the clinician must document ...
I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on ...
After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like ...
Sometimes one symptom can be used in more than one system. For example, dizziness. Although we typically think of this as a neurological symptom, sometimes cardiologists ask about dizziness and relate it to the cardiovascular system.
In the citations section of this entry, there are references for symptoms ...
By: Codapedia Editor (Oct/15/2015)
The Documentation Guidelines describe family history as:
a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk
This family history is a review of the illness's, health status, and cause of death of close members of the patient's ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 21st, 2015 - Last Review/Update August 7th, 2017
The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).
TC - Technical component Modifier may be ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 17th, 2015
The first three characters of an ICD-10 code designate the category of the diagnosis.
The next three characters (characters three through six) correspond to the related etiology (i.e., the cause, set of causes, or manner of causation of a disease or condition), anatomic site, severity, or other vital clinical details.
The seventh character is ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 17th, 2015 - Last Review/Update August 7th, 2017
ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care e.g. Initial, subsequent, sequelae
2. Injury site Be as specific as possible
3. Etiology How was the injury sustained (e.g. sports, ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 17th, 2015
Documentation assessment and gap analysis is important in ICD-10-CM/PCS. Clinical documentation will also affect code assignment and relative weight associated with payment. To read more information on problem areas with documentation issues read AHIMA's article.
...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 8th, 2015
SOAP notes (subjective, objective, assessment, plan)
Each letter in “SOAP” is a specific heading in the notes:
SOAP is an acronym for “subjective” ( S ) or the patient’s re-response and feeling to treatment, “objective” (O) or the observations of the clinician, “assessment” (A) or diagnosis of the problem, and “procedures accomplished ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 7th, 2015
ICD-10 will require more specificity in your documentation requirements. It is important to train your staff along with Dentists. Take a look at the specific areas that will be required documentation for Dental:
Type of condition
Onset - acute or chronic
Etiology (cause)
Anatomical location and laterality if laterality applies
Severity - mild, moderate or severe
Stages ...
By | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Director of Communications, ChiroCode
In my 20 years of professional bull riding I have had many highs and lows. There were times when the rankest of bulls couldn’t throw me and times when I couldn’t ride a rocking chair. When in a slump, what always worked for me, and for the ...
By ChiroCode | Published January 26th, 2015 - Last Review/Update January 30th, 2017
Documentation is essential to establishing medical necessity and the level of services provided to the patient. Treatment plans and outcome assessments are crucial elements to thorough documentation.
This page is only a general listing of documentation resources for chiropractic. More thorough and detailed explanations are found in Section D-Documentation in the ...
Durable Medical Equipment - Documenting Continued Use
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Treating physicians’ records often omit documentation of a beneficiary’s continuing use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). By Medicare statute, lack of physician documentation regarding a beneficiary’s continued need and use of an item of DMEPOS will result in claim denials. Many “model charts” from various clinical ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
It is time to start improving your clinical documentation to prepare your practice for ICD-10.
Select the codes most often used in your practice. Now, you need to determine if your current documentation is sufficient to support ICD-10. It would be best to assume it is not, since ICD-9 was not ...
By | Published November 21st, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnoses code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, I have listed some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees:Â Fee ...
Conducting a Gap Analysis for Your Documentation & Billing Systems
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 17th, 2014 - Last Review/Update January 30th, 2017
What is a Gap Analysis?
A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. This ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 20th, 2014 - Last Review/Update January 30th, 2017
When determining the type of approach taken in a surgical procedure, it is important to review not only the title of the report but also the body of the report to locate the method used.
Somewhere in the body of the report, and always preferably in the title, scope, endoscope, endoscopy ...
ICD-10 TIP of the MONTH: The Documentation of Procedures
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
To assist you in understanding the key definitions related to documenting procedures in ICD-10, see below for a list of terms to be used in your documentation. Brought to you by Crozer Keystone ICD-10 tip of the month.
Examples:
Alteration - Modifying the anatomic structure of a body part without affecting ...
Clinical documentation; Supporting good patient care and proper ICD-10 coding - VIDEO
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Supporting good patient care and proper coding in an ICD-10 environment.
Speaker Joe Nichols MD presenting training video on Clinical Documentation: (ICD-10 Webinar).
...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 3rd, 2014 - Last Review/Update January 30th, 2017
MedScape is offering a free training activity for healthcare providers who will be involved in clinical documentation with ICD-10.
This activity is to make providers aware of the key elements of good clinical documentation.
CME/CE Released: 09/15/2014; Valid for credit through 09/15/2015
Link
...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update January 25th, 2017
Be sure you have office procedures in place to keep an eye on the time frame of your claims: Claims denied by Medicare for “untimely submission” are not eligible for appeal. In fact most carriers do not afford you an appeal if timely filing is an issue; there are only ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
By | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Medicare covers a one-time Initial Preventive Physical Examination (IPPE), also referred to as the “Welcome to Medicare†visit.  IPPE is a unique benefit available only to patients newly enrolled in the Medicare Program and must be received within the first 12 months of the effective date of their Medicare Part ...
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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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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 ...
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.
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.
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!
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.
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.
Documentation Mistakes that Can De-value your Personal Injury Case
Don't make mistakes that will cost you money. In this presentation Dr. Gwilliam will show you how to avoid documentation errors that attorneys and IMEs can use to decrease the value of your personal injury case. Learn how to show medical necessity through the codes you assign and support it properly in the documentation. Create goals that tell the story and establish the need for care. Avoid cloned records. All this and more in this fun-filled presentation.
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.
How to prove medical necessity.
How to report this information to Medicare.
How to determine Maximum Medical Improvement.
Earlier this year the Medicare Administrative Contractors revised their Local Coverage
Determinations. There are some changes that will affect how you document your Medicare
visits. Medicare requires that you have a treatment plan with measurable goals. The treatment plan also serves the purpose of providing you and your patient with a roadmap of care. In this
webinar Dr. Short will show you:
What specific elements Medicare requires in each treatment plan.
How to use common clinical tools to develop effective treatment plans.
Why the treatment plan is critical to proving medical necessity and overall patient care.
This webinar will give you practical information that you can apply in your office the next day.
You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list- signup/ or by following the link provided in my e-
mail update. They will be available by the Monday prior to the webinar presentation.
In this webinar, Dr. Gwilliam will go over code updates for 2018. He will show you some new ways to look at Episodes of Care, which is critical for Medicare. You'll learn how to use self audit checklists to make sure you survive the inevitable third party audit. Confession: This webinar is really just a pitch for all of the cool new things we are adding to the 2018 DeskBook, which will be released in October. We will give you the low down on what you need to be successful next year.
The New Local Coverage Determinations and What They Mean to You
Earlier this year the Medicare Administrative Contractors revised their Local Coverage Determinations. There are some changes that will affect how you document your Medicare
visits.
In this webinar, Dr. Ron Short will explain the changes to the Local Coverage Determinations and how to utilize them in your practice.
You will learn:
What has changed and how it will affect you
What has stayed the same
How to document Medicare Visits
How to Document Subsequent Visits for Medicare and Everyone Else REALLY REALLY FAST Without Driving Yourself Crazy in the Process
Everyone seems to want to know how to document WELL, but FAST. Dr. Friedman will explain and demonstrate how this is not only POSSIBLE to do for Medicare, but for everyone else, too. We just need to find that ONE format of documentation that will work for EVERYONE, so there's ONE LESS THING for us to think about. Believe it or not, Medicare has actually made it EASY for us to document well and fast. Dr. Friedman will take you through the steps, from his perspective of practicing for more than 30 years and from reviewing records, performing IMEs and teaching documentation seminars nationally for years
In this special webinar for the Kentucky Association of Chiropractors, we will review the latest evidence available about effective care plans for chiropractors. More information is found in Chapter 4.5 of the 2017 ChiroCode DeskBook, which is all about creating care plans that are evidence-based and focused on measurable goals. Proper care plans still allow the doctor to take care of patients based on their clinical skill, but also show medical necessity to outsiders. This presentation is based on an updated article published last year, and available free here: http://www.jmptonline.org/article/S0161-4754(15)00184-0/fulltext
In this webinar, Dr. Friedman will discuss the initial new patient exam and how it doesn't do what we THINK it does for our documentation. He'll also discuss what establishes the NEED to begin care and justifies the NEED to continue care. Understanding this concept is CRITICAL for ALL patients, regardless who is paying for the care.
In this webinar, get a sneak peak at how ChiroCode audits a typical evaluation encounter. Do you document functional loss? Are you using outcome assessment tools appropriately? Does your treatment plan include measurable goals? Do you document complicating factors? Answer all these questions and more in this action-packed half hour with Dr. Gwilliam.
Chapter 4.3 - Evaluations 3: Diagnosis and Treatment plans
Let Dr. Gwilliam, ChiroCode's Vice President, walk you through the rest of Chapter 4.3 on documenting for evaluations and re-evaluations. This is part 3 of 3.
...
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