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Documentation Articles and Resources
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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. Related Topics: Find-A-Code's Tools & ResourcesNCD’s/LCD’s/ArticlesSearch NCDs, LCDs, and Articles for Documentation Requirements, Limitations of Coverage, and/or Medical Necessity. Commercial Payer PolciesView Clinical Indications for Medical necessity on procedures, Suggested Code Selection, and Documentation Requirements. CPT® Assistant ArchivesSearch the CPT® Assitant Archives by code or keywords. AHA Coding Clinic® ICD9/10 & HCPCSSearch the AHA Coding Clinic® Articles by Keywords DecisionHealth® - Pink Sheets, Part BSearch over 30,000 Articles from Coder Pink Sheets, Part-B News, Answer Books JustCoding Newsletter® NEWJustCoding® Newsletter Search by keywords BC Advantage +20 CEUsBilling & Coding - Magazine, Webinars, CEUs, Article Archives Find-A-Code ArticlesMedical Coding and Billing Articles Find-A-Code Focus NewsletterFree weekly email that includes coding tips, industry news, articles, and information about Find-A-Code. PDGs- Provider Documentation GuidesPDGs- Provider Documentation Guides General Links and ResourcesMedicare Provider ComplianceMedicare Quarterly Provider Compliance Newsletter Standard Documentation RequirementsStandard Documentation Requirements for All Claims Submitted to DME MACs Documentation of Medical NecessityDocumentation and Coding that Demonstrates Medical Necessity Compliance with Documentation RequirementsComplying with Medical Record Documentation Requirements Signature Requirement Q&A'sSignature Requirement Questions and Answers Related TopicsCDIClinical Documentation Improvement Select the title to see a summary and a link to the full article. October 4th, 2021 Watch out for New ICD-10-CM CodesBy Wyn Staheli, Director of Research | Published October 4th, 2021 New ICD Codes for: Low Back Pain, Cervicogenic Headache, Non-Radiographic Axial Spondyloarthritis (nr-axSpA), and Social Determinations of Health (SDOH). These codes became effective on October 1, 2021. September 2nd, 2021 Polysomnography Services Under OIG ScrutinyBy Raquel Shumway | Published September 2nd, 2021 The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.”
So what are those requirements?
July 28th, 2020 OIG Report Highlights Need to Understand GuidelinesBy Wyn Staheli, Director of Research | Published July 28th, 2020 A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers. May 5th, 2020 ICD-10-CM - Supplement information for E-Cigarette/Vaping ReportingBy Christine Woolstenhulme, QCC, QMCS, 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 - ... April 21st, 2020 Special COVID Laboratory Specimen Coding InformationBy 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. April 20th, 2020 Dismal OIG Report on TelemedicineBy 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. October 1st, 2019 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: ... August 2nd, 2019 The Slippery Slope For CDI SpecialistsBy Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019 Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.
Many of you in this industry are ... July 22nd, 2019 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 ... July 9th, 2019 The Importance of Medical NecessityBy 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 ... June 13th, 2019 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 ... June 6th, 2019 How to Code Ophthalmologic Services AccuratelyBy 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 ... May 13th, 2019 Electrical Stimulation and Electromagnetic Therapy DevicesBy 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. May 6th, 2019 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 ... April 23rd, 2019 Let's Talk High Risk E/M ServicesBy 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 ... April 23rd, 2019 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 ... April 22nd, 2019 Auditing Chiropractic ServicesBy 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. March 21st, 2019 The Impact of Medical Necessity on High Level E/M ServicesBy 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. ... March 1st, 2019 Understanding NCCI EditsBy 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 ... February 12th, 2019 Coding Medicare Initial Preventive Physical Exams (IPPE)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 ... January 25th, 2019 Medical Necessity vs. Documentation for Inpatient ServicesBy 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 ... January 23rd, 2019 How to Report Co-Surgeons Using Modifier 62By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019 Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ... January 22nd, 2019 Home Oxygen TherapyDecember 7th, 2018 Keeping Up to DateBy 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... November 30th, 2018 Auditing looking between the linesBy 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... November 7th, 2018 Medi-Cal Coverage Criteria for Hospital Beds and AccessoriesBy Raquel Shumway | Published November 7th, 2018 Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required. October 30th, 2018 Documentation Requirements for Allergy Testing 10/29/2018By Christine Woolstenhulme, QCC, QMCS, 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 ... October 19th, 2018 We've Always Done It This Way and Other Challenges in EducationBy 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... August 3rd, 2018 When Medical Necessity and Medical Decision Making Don't MatchBy 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... July 18th, 2018 Patients Over Paperwork?! We have Great News!By Christine Woolstenhulme, QCC, QMCS, 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 ... July 9th, 2018 Documentation: Face to Face for Home Health CertificationBy Christine Woolstenhulme, QCC, QMCS, 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 ... June 26th, 2018 WHO Said ICD-11 is Coming SoonBy Christine Woolstenhulme, QCC, QMCS, 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 ... June 14th, 2018 Home Oxygen Therapy -- CMN for OxygenBy Raquel Shumway | Published June 14th, 2018 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. May 16th, 2018 Key Performance Indicators RevisitedBy 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... April 23rd, 2018 Brooklyn Chiropractor OIG Report - Lessons LearnedBy 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. April 23rd, 2018 Critical Care DocumentationBy Scott Kraft, CPC, CPMA | Published April 23rd, 2018 - Last Review/Update May 2nd, 2018 Critical care documentation should show critical need for the patient AND immediate action by the provider.... April 19th, 2018 Proper Record Keeping and DocumentationBy | Published April 19th, 2018 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 ... March 27th, 2018 Home Oxygen Therapy -- A Face-to-Face EncounterBy Raquel Shumway | Published March 27th, 2018 - Last Review/Update June 14th, 2018 What is required for a Home Oxygen Therapy, Face-to-Face Encounter. March 26th, 2018 Documentation for Evaluation and Management (E/M) ServicesBy | 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 ... March 21st, 2018 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. March 13th, 2018 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. March 9th, 2018 The Comprehensive Error Rate Testing ProgramBy Frank Cohen, MBA, MPA | Published March 9th, 2018 - Last Review/Update April 12th, 2018 With nearly a million physicians in this country, how do auditing organizations determine whom to audit? March 9th, 2018 Documentation for Ordering Oxygen Supplies and EquipmentBy Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 26th, 2018 The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment. March 9th, 2018 Documentation for Negative Pressure Wound TherapyBy Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy. March 9th, 2018 Documentation for Surgical DressingsBy Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for surgical dressings.
March 9th, 2018 Documentation for Enteral NutritionBy Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ... March 8th, 2018 Documentation for Home Blood Glucose Monitors (BGM)By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018 The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)... March 8th, 2018 Documentation for Therapeutic CGMs and Related SuppliesBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018 The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies March 8th, 2018 Documentation for Manual WheelchairsBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018 The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases.... March 8th, 2018 Documentation for Lower Limb ProsthesisBy 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 ... March 8th, 2018 Documentation for Bacterial Culture Lab TestsBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018 The Medicare Learning Network provides guidance on how to prevent denials of Bacterial Culture Laboratory Tests March 8th, 2018 Documentation for Bacterial Culture Lab OrdersBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018 The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests... March 8th, 2018 Documentation for Power Tilt/Recline Seating Systems for WheelchairsBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018 The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems... March 8th, 2018 Documentation for Ostomy SuppliesBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018 The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies.... March 8th, 2018 Documentation for Home Health Services (Part A non DRG)By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018 The Medical Learning Network provides coverage guidance, which should be documented, for home health services. March 8th, 2018 Documentation and Orders for Respiratory Assistive DeviceBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines. March 8th, 2018 Documentation and Orders for Laboratory TestsBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests. March 8th, 2018 Documentation for Skilled Nursing FacilitiesBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF). March 8th, 2018 Documentation for Inpatient Rehabilitation FacilitiesBy Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018 The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF). February 12th, 2018 The Coder as the Last, Best Hope for the Right DRGBy 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.... February 1st, 2018 Pre-Existing or Gestational?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 ... February 1st, 2018 Traumatic Subluxation Coding ControversyBy 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 ... January 29th, 2018 Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5BBy 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 ... January 26th, 2018 Creating a Culture of Compliance in 2018By 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.... January 24th, 2018 Better Office Communication Leads to Stronger RCMBy 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. ... January 23rd, 2018 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. ... January 9th, 2018 Antiresorptive Osteonecrosis of the JawsBy Find-A-Code | Published January 9th, 2018 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 ... January 9th, 2018 GeneSight Psychotropic Testing and DocumentationBy Find-A-Code | Published January 9th, 2018 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 ... January 9th, 2018 Coverage and/or Medical Necessity for the Use of Hyaluronan or DerivitiveBy 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 ... January 4th, 2018 Reimbursement for Therapy StudentsBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Proper Usage of Electrical StimulationBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Initial Evaluation Codes for PT's and OT'sBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 PT and OT Reevaluation CodingBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 General Physical Therapy Modality GuidelinesBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Diathermy eg Microwave Use and DocumentationBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Ultrasound TherapyBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Hydrotherapy GuidelinesBy Find-A-Code | Published January 4th, 2018 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 ... January 4th, 2018 Modifiers 54-55, split surgical and postoperative careBy 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 ... December 12th, 2017 Documenting the Location and Correct CodingBy Christine Woolstenhulme, QCC, QMCS, 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 ... December 1st, 2017 Auditing the Use of a ScribeBy Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published December 1st, 2017 - Last Review/Update January 31st, 2018 A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider...... November 30th, 2017 Coding Carpal Tunnel SyndromeBy 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? November 24th, 2017 Inpatient critical care: When is it ok to question the medical necessity?By Stephanie Allard, CPC, CEMA, RHIT | Published November 24th, 2017 - Last Review/Update January 31st, 2018 While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary..... October 27th, 2017 Speech-Language Pathology Services Policy from UniCareBy 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 ... October 20th, 2017 A P.A.R.T. TemplateBy Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 20th, 2017 - Last Review/Update February 5th, 2019 Here at ChiroCode we are often asked for examples of perfect forms to use in the office. As such we have developed some.
October 20th, 2017 PFSH Documentation: Q and ABy 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? October 13th, 2017 So, How Do You Decide if a Service was Provided?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..... October 6th, 2017 Acronyms and Abbreviations: When You Fall into the Grey AreaBy 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.... October 6th, 2017 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. ... September 29th, 2017 Does Every Visit Need to Document Quality and Quantity of Pain & Update the Treatment Plan?By ChiroCode | Published September 29th, 2017 - Last Review/Update February 5th, 2019 Does every single visit need to document quality and quantity of pain and an update to the treatment plan? September 25th, 2017 Q/A: What is the Proper Usage of Code 97150?By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published September 25th, 2017 - Last Review/Update February 5th, 2019 What is the proper usage of CPT 97150 and what are the documentation requirements for that? September 20th, 2017 Bladder/Urothelial Tumor Markers (Jurisdiction F)By Christine Woolstenhulme, QCC, QMCS, 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 ... September 15th, 2017 Copy and Paste: The Real Rules PrevailBy 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..... September 14th, 2017 Double Dipping in the History of the Evaluation and Management NoteBy 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 ... September 1st, 2017 Quick Tip from ChiroCode -- DocumentationBy ChiroCode | Published September 1st, 2017 - Last Review/Update January 31st, 2019 Documentation Solutions, a quick tip video by Dr Gwilliam. September 1st, 2017 How to Use Guidelines When the Auditor Challenges YouBy Dr Ronald J. Farabaugh | Published September 1st, 2017 - Last Review/Update February 5th, 2019 General Rules/Facts Related to the Proper Use versus Misuse of Guidelines August 18th, 2017 The Incredible Disappearing ConsultationBy J. Paul Spencer, CPC, COC | Published August 18th, 2017 - Last Review/Update January 25th, 2018 In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255 for inpatient). June 29th, 2017 Focus on Clinical Documentation to Improve Coding and Audit ResultsBy 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 ... June 13th, 2017 Documentation for Physical TherapistBy Christine Woolstenhulme, QCC, QMCS, 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 ... May 30th, 2017 Q/A: How do I Bill Class 4 Deep Tissue Hot Laser Treatment?By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published May 30th, 2017 - Last Review/Update February 8th, 2019 Is there a way to bill out for Class 4 deep tissue hot laser treatments? May 22nd, 2017 Maintenance Visit DocumentationBy 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
... April 28th, 2017 Can I be Forbidden from Billing 99204 or 99214?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? April 20th, 2017 Therapy Plan of CareBy Christine Woolstenhulme, QCC, QMCS, 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 ... March 2nd, 2017 Insufficient DocumentationBy Christine Woolstenhulme, QCC, QMCS, 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 ... February 27th, 2017 Documentation: Face to Face for Home Health CertificationBy Christine Woolstenhulme, QCC, QMCS, 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. ... January 23rd, 2017 Why Should I Document a Differential Diagnosis?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. January 20th, 2017 Pre-Existing or Gestational?By Christine Woolstenhulme, QCC, QMCS, 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 ... January 13th, 2017 Whiplash DamagesBy 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. December 7th, 2016 Insurance Denying Everything as MaintenanceBy ChiroCode | Published December 7th, 2016 - Last Review/Update March 4th, 2019 Are you having a difficult time getting reimbursed? Are claims being denied because the insurance classifies everything as maintenance? November 30th, 2016 When can I Bill for a Consult E/M Code?By | Published November 30th, 2016 - Last Review/Update March 5th, 2019 Physician referrals -- When can we bill a consult code? If we do not have the referral on our referral pad can we bill the consult code? November 19th, 2016 Lack of Medical NecessityBy 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 ... September 24th, 2016 Medicare Improper Payment Report for Behavioral Health Services (2015)By Wyn Staheli, Director of Research | Published September 24th, 2016 Medicare claims review sheds light on problem areas for behavioral health providers. July 29th, 2016 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... July 29th, 2016 Can we bill a low level E/M with every procedure?By | Published July 29th, 2016 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... July 28th, 2016 Cloned documentation on OIG radar screen in 2014By | Published July 28th, 2016 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... July 19th, 2016 Documentation GuidelinesBy | Published July 19th, 2016 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... June 9th, 2016 Understanding and Using Taxonomy Codes to Maximize ReimbursementBy | 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 ... January 6th, 2016 Family meetings without the patient presentBy | Published January 6th, 2016 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... December 11th, 2015 The Benefit of Checking BenefitsBy | Published December 11th, 2015 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... December 2nd, 2015 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... December 2nd, 2015 Past medical, family and social history - Documenting and auditing the history section of an E/M serviceBy | 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... December 2nd, 2015 History of the present illness - HPI Rules from the Documentation GuidelinesBy | 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... December 2nd, 2015 CMS clarifies the ways physician practices can respond to additional documentation requestsBy | 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... December 1st, 2015 The Joy of Medicine - AMA wants to Restore the Joy of MedicineBy Christine Woolstenhulme, QCC, QMCS, 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 ... November 24th, 2015 You do not need to change or rewrite your original ordersBy 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 ... November 24th, 2015 What counts as social history?By | Published November 24th, 2015 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... November 20th, 2015 Documentation of Pressure UlcersBy Find-A-Code | Published November 20th, 2015 Documentation of Pressure Ulcers, read entire article by Wound Consultants Inc.
... November 19th, 2015 Documentation Guidelines - E/M auditingBy | Published November 19th, 2015 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 ... November 19th, 2015 Medical Necessity is not Medical Decision MakingBy | Published November 19th, 2015 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 ... November 19th, 2015 Not Documented, Not Done: Medicare Myth or Rule?By | Published November 19th, 2015 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 ... November 19th, 2015 Review of Systems - ROS Rules for AuditingBy | Published November 19th, 2015 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 ... November 12th, 2015 Family history--what countsBy | Published November 12th, 2015 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 ... September 21st, 2015 Documentation and Reimbursement for TestingBy Christine Woolstenhulme, QCC, QMCS, 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 ... September 17th, 2015 ICD-10 -Understanding Format and StructureBy Christine Woolstenhulme, QCC, QMCS, 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 ... September 17th, 2015 Injuries DocumentationBy Christine Woolstenhulme, QCC, QMCS, 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, ... August 17th, 2015 Clinical Documentation Guidance for ICD-10-CM/PCSBy Christine Woolstenhulme, QCC, QMCS, 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.
... August 10th, 2015 Documentation Requirements for Therapy ServicesBy Christine Woolstenhulme, QCC, QMCS, 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 ... July 8th, 2015 SOAP notes (subjective, objective, assessment, plan)By Christine Woolstenhulme, QCC, QMCS, 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 ... July 7th, 2015 Dental Documentation with ICD-10By Christine Woolstenhulme, QCC, QMCS, 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 ... February 26th, 2015 Chiropractic Billing 101: A Basic GuideBy | 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 ... January 26th, 2015 Documentation ResourcesBy 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 ... December 4th, 2014 Durable Medical Equipment - Documenting Continued UseBy Christine Woolstenhulme, QCC, QMCS, 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 ... November 21st, 2014 Get Ready! Improve your Clinical Documentation!By Christine Woolstenhulme, QCC, QMCS, 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 ... November 21st, 2014 Coding for Laser TherapyBy | 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 ... November 19th, 2014 Getting Ready for 2015By | 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 ... November 17th, 2014 Conducting a Gap Analysis for Your Documentation & Billing SystemsBy 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 ... October 20th, 2014 Clarification of Equipment and Approach in CodingBy 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 ... October 16th, 2014 ICD-10 TIP of the MONTH: The Documentation of ProceduresBy Christine Woolstenhulme, QCC, QMCS, 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 ... October 16th, 2014 Clinical documentation; Supporting good patient care and proper ICD-10 coding - VIDEOBy Christine Woolstenhulme, QCC, QMCS, 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).
... October 3rd, 2014 ICD-10 and Clinical Documentation CME/CEBy Christine Woolstenhulme, QCC, QMCS, 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
... August 26th, 2014 Un-Timely Filing - ZERO ReimbursementBy Christine Woolstenhulme, QCC, QMCS, 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 ... August 7th, 2014 Durable Medical Equipment, Prosthetics, Orthotics and SuppliesBy Christine Woolstenhulme, QCC, QMCS, 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 ... July 16th, 2014 G0402: Medicare Preventive VisitBy | 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 ... December 31st, 2001 Commonly Asked Chiropractic Coding QuestionsBy ChiroCode | Published December 31st, 2001 - Last Review/Update August 19th, 2015 Commonly Asked Questions:
1. Retention of Records
2. 97140 Denials
3. Exercise Equipment
4. Coding for BioFreeze
5. 97014 or G0283
6. Billing for additional insurance forms
7. Report of Findings
8. Laser therapy
9. Spinal Decompression
10. Diagnosis Coding – 4th and 5th digit
11. Re-Reading X-rays
12. Outcomes Assessment Questionnaires
13. Accounts Receivable
14. 15-Minute Units
15. E/M and CMT There are more articles. View all articles... View articles for the current subject by subtopic:
(There are no webinars at this time, please check back later.) ACA Clarifies Aetna PolicyAmerican College of Radiology Practice Parameter for Communication of Diagnostic Imaging FindingsCMS-Novitas Solutions: E/M Documentation Auditor's InstructionsCMS-Novitas Solutions: Specialty Exam: CardiovascularCMS-Novitas Solutions: Specialty Exam: DermatologyCMS-Novitas Solutions: Specialty Exam: Ears, Nose and ThroatCMS-Novitas Solutions: Specialty Exam: EyesCMS-Novitas Solutions: Specialty Exam: Genitourinary (Female)CMS-Novitas Solutions: Specialty Exam: Genitourinary (Male)CMS-Novitas Solutions: Specialty Exam: Hematologic/Lymphatic/Immunologic ExaminationCMS-Novitas Solutions: Specialty Exam: MusculoskeletalCMS-Novitas Solutions: Specialty Exam: NeurologyCMS-Novitas Solutions: Specialty Exam: RespiratoryCoding and Billing WorkshopsCoding_Changes_2014Complaince Program Guidance for Third-Party Medical Billing CompaniesCompliance Program Guidance for Ambulance SuppliersCompliance Program Guidance for Clinical LaboratoriesCompliance Program Guidance for Home Health AgenciesCompliance Program Guidance for HospicesCompliance Program Guidance for HospitalsCompliance Program Guidance for Individual and Small Group Physician PracticesCompliance Program Guidance for Medicare+Choice OrganizationsCompliance Program Guidance for Nursing FacilitiesCompliance Program Guidance for Pharmaceutical ManufacturersCompliance Program Guidance for the Durable Medical Equipment, Prosthetics, Orthotics, and Supply IndustryGastro_ArticleGeriatricHHS, Justice Department warn hospitals on EHR-related payment fraudHome Health Billing FAQsMedlinePlusOIG Compliance Program for Individual and Small Group Physician PracticesOIG Compliance Program for Individual and Small Group Physician Practices - Federal RegisterPressure Ulcer GuidelinesProvider Compliance Tips for Diabetic Test StripsProvider Compliance Tips for Hospital Beds and AccessoriesProvider Compliance Tips for Infusion Pumps and Related DrugsProvider Compliance Tips for Laboratory Tests - Blood CountsSonomaSupplemental Compliance Program Guidance for HospitalsSupplemental Compliance Program Guide for Nursing Facilities (There are no podcasts at this time, please check back later.)
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