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Practice Management Topics Page

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Watch Out for People-Related 'Gotchas'

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Attestations Teaching Physicians vs Split Shared Visits

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Practice Management Articles & Resources Articles

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Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?

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Question  We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate ...

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Prioritize Your Patient's Financial Experience

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For many years, the ChiroCode DeskBook has emphasized the need for providers to firmly establish the patient’s financial responsibility through clear communication. We even created a “Patient Financial Responsibility Acknowledgment Form” to help providers with this process. Lately, the lack of pricing transparency has been in the news and even ...

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Auditing Chiropractic Services

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

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Watch out for People-Related ‘Gotchas’

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In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...

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Understanding NCCI Edits

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

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Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?

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It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?

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Attestations Teaching Physicians vs Split Shared Visits

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Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...

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Are You Protecting Your Dental Practice From Fraud?

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With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...

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Auditing looking between the lines

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

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Present on Admission POA Indicator

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This article will focus on the Present on Admission (POA) indicator which is used as a method of reporting whether a patient’s diagnoses are present at the time they are admitted to a facility. We’ll look at a few scenarios to determine the correct reporting of POA and the impact...

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

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

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Wolters Kluwer Drug Pricing

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Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...

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HIPAA Handling Patient Requests for Medical Record Restriction

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Healthcare compliance professionals frequently face confusing situations about sharing of protected health information (PHI). The Health Insurance Portability and Accountability Act (HIPAA) supports the protection of privacy of medical records. However, even when a patient does not authorize sharing of his record, there are permitted uses and disclosures, such as...

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The Potential Impacts of a Flat Rate EM Reimbursement on our Industry

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The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...

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Q/A: Do I Have to Accept Any New Patient?

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Question: Is it legal for us to not allow a patient to be seen in our office if their parents have bad debt with us?

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Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement

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We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...

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Pricing for ASC’s and APC’s

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For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...

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Documentation: Face to Face for Home Health Certification

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

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How Does the Physician Compare Website Affect You?

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The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...

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The Money in MIPS

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Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), recently announced that 91% participated in the first year of the Quality Payment Program (QPP), barely squeaking by their goal of 90%....

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Three Ways Bundled Payments Can Be a Success

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Bundled payment models continue to attract interest for their potential benefits over traditional fee-for-service payment models. With bundled payments, also known as episode-based payments or packaged pricing, a group of providers is reimbursed based on a contracted price to cover all of the care and services related to a particular ...

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Routine Waiver of Patient Out of Pocket Expenses

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Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient's co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations....

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Key Performance Indicators Revisited

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

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The Devil is in the Data Details

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As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.

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Saving Time and Money with Automated Insurance Eligibility Verification

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The healthcare revenue cycle contains multiple potential pinch points for the parties involved: patients don’t enjoy dealing with insurance companies and have trouble understanding their benefits, and they especially hate being responsible for surprise medical costs that aren’t covered by their insurance plan. Healthcare providers compete in a challenging...

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FHIR Revisited

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Like a moth to a flame, we periodically have to take a close look at FHIR. As mentioned in the March 26 blog post, interoperability was the hot topic at HIMSS, and FHIR is at the blazing edge of interoperability...

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Proper Record Keeping and Documentation

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

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Dentists Submitting Claims to Medicare

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When a Dental provider is treating a Medicare Beneficiary, it is important to get a copy of the Medicare card to verify the patient's medical benefits, provider eligibility and claims address/submission prior to submitting a claim. CMS is in the process of changing Medicare Policy Numbers, so you may see ...

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Use it or Lose it - How We Can Help!

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If you don’t use the correct information or document the proper information and submit a medical claim you will lose!  You will lose reimbursement, could be excluded from participating in Federal Health Care programs, you could possibly lose your license and family time. The government has every tool they need, you ...

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What Do Patients Expect in 2018?

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Evolutions in technology continue to merge with a trend toward consumerism in healthcare. As a result, patients are expecting a different kind of experience in managing their healthcare....

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The Comprehensive Error Rate Testing Program

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

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Increase Revenue by Outsourcing Medical Billing

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Many practices are starting to weigh the benefits outsourcing medical billing compared to keeping it in-house....

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Health Information Exchange and Trusted Exchange Frameworks

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Despite progress in health IT, Health Information Exchange (HIE) remains squarely in toll booth mode, with gated stops and slowdowns that may or may not permit information to move forward. ...

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The Comprehensive Error Rate Testing Program

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

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Using a 2015 Certified EHR in MIPS Year 2

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The following information is from BC Advantage. As of Dec 31, 2017, Acumen EHR v8.0 achieved Office of the National Coordinator for Health Information Technology (ONC-Health IT) 2015 edition certification! What's a 2015 CEHRT?A CEHRT (Certified EHR Technology) is defined by CMS specifically for their incentive payment programs such as...

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Don’t Be Hesitant About Collecting Co-Pays

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If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...

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Adjusting Your Collection Strategies to HDHPs

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High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....

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Mobile Health: Growing Engagement and New Responsibilities

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This week I'm blogging about an M-word. Not MACRA or MIPS, but Mobile Health or mHealth....

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Developing Coding Policies for Compliance

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Every physician practice depends upon correct coding and billing for their financial success. Coding drives reimbursement. All of the resources available for coding information and guidance are meaningless without the practice manager translating it into provider-specific coding policies and compliance plan. As a practice manager, you need to develop a ...

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Dental and Medical- Controlled Substance Awareness

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As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...

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Referring and Ordering Physician - CMS-1500 Box 17

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Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item ...

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Prescription Drug Discount Program

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Prescription drugs can be quite costly for those who are uninsured or underinsured. Prohibitive costs have been shown to lead to poor patient outcomes because medications are not taken as prescribed. Medicare has taken steps to address this problem with their Medicare Advantage value based plans (see referenced "Medicare Expands Value ...

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UCR Pricing, What is it?

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UCR (Usual, Customary, and Reasonable) pricing is a method of generating healthcare pricing based on the average pricing in a particular geographic location.  Gathering information on pricing based on what other providers in that area is charging is commonly used for a fee or payment reference, as it gives a basis ...

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Better Office Communication Leads to Stronger RCM

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

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Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines

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The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ...

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Diagnosis Coding with Diagnostic Testing

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Adequate documentation is an essential part of selecting a correct code in any setting. When providers order a test, the information that they document regarding the test results determines the primary and secondary diagnosis codes a coder assigns. If a physician confirms a diagnosis based on the results of a diagnostic ...

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Reimbursement Guides
2020 Edition

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

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