Compliance - Articles

REMINDER: CMS Discontinuing the use of CMNs and DIFs- Eff Jan 2023 Claims will be DENIED!
December 19th, 2022 - Chris Woolstenhulme
Updated Article - REMINDER! This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.
Costly Mistakes Every Medical Billing Department Can Avoid
October 27th, 2022 - Find-A-Code
No business owner likes mistakes. Mistakes cost time and money to fix; they harm a company's reputation; they are bad news all around. Every private practice and healthcare clinic with an in-house billing department knows exactly what we're talking about.
Seven Major Changes Proposed by CMS in the 2023 Proposed Rule
October 24th, 2022 - Aimee Wilcox
As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.
HIPAA Compliance is a Must for Medical Billers and Coders
October 21st, 2022 - Find-A-Code
The medical coding and billing industry is regulated in terms of how it can collect and utilize information. Anyone involved in medical billing and coding, be it as a business owner or employee, must follow all the rules necessary to maintain HIPAA compliance. Needless to say, compliance is a must. Washington doesn't give the industry a choice.
No Surprises Act Requires More Transparent Medical Billing
September 9th, 2022 - Find-A-Code
Congress passed the No Surprises Act as part of the 2021 Consolidated Appropriations Act. No Surprises was fully implemented as of the start of this year. With it now being the law of the land, healthcare providers are legally obligated to provide more transparent medical billing so that patients do not receive surprise bills for out-of-network care or in-network care provided by an out-of-network clinician.
Mid-Year Coding Updates and A Quick Look at ICD-10-CM Changes
August 4th, 2022 - Aimee Wilcox
Mid-year HCPCS and Category III codes have been released for reporting purposes and at the same time we are being inundated with a large number of ICD-10-CM code changes. What are Category III codes and what changes were made in these coding updates? Read this article and sign up for the upcoming webinar when we will discuss the newest code changes, including an overview of what ICD-10-CM changes will look like.
Minor Procedures Get a Major Sting in the 2021 CERT Report
May 3rd, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The 2021 Comprehensive Error Rate Testing report provides important lessons on exactly what errors are being found during chart reviews and how provider organizations can be proactive in their approach to quality documentation that not only supports the services provided to the patient but allows the providers to work in an environment of knowing what must be documented to support what they submit to the payer.
How to Reduce the Risk of Copy and Paste
April 27th, 2022 - Erica E. Remer, MD, CCDS
Providers should never C&P (copy and paste) material they have not read nor vetted for accuracy. A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his surgery, it was reported that the surgeon referred to “DVT/VTE Prophylaxis/Anticoagulation” and another note read, “already ordered.” “DVT...
The Case of the Missing Signature
March 10th, 2022 - David M. Glaser, Esq.
It’s important to remember that Medicare manuals are not binding, and they can’t “require” anything, including signatures. Regulatory framework is constantly changing. Never assume you know all of the rules, even if you carefully study them all the time. New things are constantly appearing....

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Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Compliance in the Dental Office or Small Practice
June 29th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
March 31st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
HIPAA Penalty Changes
January 11th, 2021 - Wyn Staheli, Director of Research
On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.
Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program
October 7th, 2020 - Wyn Staheli, Director of Research
To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.
An Infectious Disease Control Plan is Essential
October 6th, 2020 - Wyn Staheli, Director of Research
Every business encounters infections. The COVID-10 pandemic has only highlighted this fact, but considering that infectious diseases, such as the seasonal flu, are an ongoing problem, all organizations need to implement an Infectious Disease Control Plan as part of an active compliance plan because it’s required by law. Your organization must take steps to mitigate this risk to both patients and employee
Not Following the Rules Costs Chiropractor $5 Million
September 1st, 2020 - Wyn Staheli, Director of Research
Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?
OIG Report Highlights Need to Understand Guidelines
July 28th, 2020 - Wyn Staheli, Director of Research
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.
Dismal OIG Report on Telemedicine
April 20th, 2020 - Wyn Staheli, Director of Research
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.
COVID-19: Cybercrime, Telehealth, and Coding
March 25th, 2020 - Wyn Staheli, Director of Research
Your inbox is probably like mine with all sorts of announcements about COVID-19. Here are just a few reminders of things we felt should be passed along. We have heard of several cases of cybercrime related to this outbreak. For example, there was a coronavirus map which loads malware onto your ...
Inadequate Exclusion Screenings Could Put Your Practice at Risk
January 21st, 2020 - Wyn Staheli, Director of Research
Exclusion screenings require far more than just checking a name on a federal database at the time you are hiring someone. Far too many providers don’t realize that in order to meet compliance requirements, there is MUCH more involved. There are actually over 40 exclusion screening databases/lists that need to be checked.
2020 Official ICD-10-CM Coding Guideline Changes Are Here!
October 1st, 2019 - Wyn Staheli, Director of Research
It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
August 13th, 2019 - Wyn Staheli, Director of Research
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.
Are These Problems Hurting Your Practice?
July 22nd, 2019 - Wyn Staheli, Director of Research
There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.
Denial Management is Key to Profitability
July 15th, 2019 - Wyn Staheli, Director of Research
A recent article by Modern Medicine cited a report by Becker’s Hospital Review which stated that it costs approximately $118 per claim to resolve a claim denial. Granted, these were hospital claims, but the process is essentially the same for outpatient services. In fact, you could say it is...
Q/A: Can I Put the DC’s NPI in Item Number 24J for Massage Services?
July 8th, 2019 - Wyn Staheli, Director of Research
Question: Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services? Answer: While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
Rules for Rendering Unproven, Investigational or Experimental Procedures
July 1st, 2019 - Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA
If you haven’t reviewed your state guidelines or taken a recent look at third-party payer policies on unproven, investigational or experimental procedures, now is the perfect time to make sure you’re up to speed with this important information. Most providers are surprised to see commonly used devices or techniques listed ...
Q/A: Do I Really Need to Have an Interpreter?
July 1st, 2019 - Wyn Staheli, Director of Research
Question: I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true? Answer: Yes! There are both state and federal laws that need to be considered. The applicable federal laws are: Title VI of the Civil Rights Act of 1964, Americans with Disabilities ...
2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done
June 27th, 2019 - Wyn Staheli, Director of Research
The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...
Q/A: Can I Refuse to File a Patient's Medical Insurance for an Auto Accident?
June 25th, 2019 - Wyn Staheli, Director of Research
Question: Can a Chiropractor refuse to file a patients Medical Insurance for an Auto Accident? Answer: There isn't a simple answer to this question. It depends on who is responsible and state laws. Who is responsible (the auto insurance or the medical insurance) can depend on state requirements as well as who is ...
Small Breaches Can Be Subject to Large Penalties
June 21st, 2019 - Namas
Small Breaches Can Be Subject to Large Penalties We may have heard about the large fines issued by the Office for Civil Rights (OCR) against big organizations like Anthem or the University of Texas MD Anderson Cancer Center. These organizations have been in the news due to privacy breaches that constituted violations ...
What Medical Necessity Tools Does Find-A-Code Offer?
June 13th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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 ...
Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?
May 13th, 2019 - Wyn Staheli, Director of Research
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 ...
Q/A: I’m Being Audited? Is There a Documentation Template I can use?
April 29th, 2019 - Wyn Staheli, Director of Research
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942? Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...
OIG Announces - New Review For Medicare Part B Payments for Podiatry and Ancillary Services
April 23rd, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020.  The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.   Part of the ...
Watch out for People-Related ‘Gotchas’
April 15th, 2019 - Wyn Staheli, Director of Research
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 ...
Prepayment Review Battle Plan
April 8th, 2019 - Wyn Staheli, Director of Research
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
Clearing Up Some Medicare Participation Misunderstandings
March 25th, 2019 - Wyn Staheli, Director of Research
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
Q/A: How do we Know Which Codes a Payer Will Allow?
March 22nd, 2019 - Wyn Staheli, Director of Research
How do we know which codes a payer will allow? The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...
Date of Service Reporting for Radiology Services
March 7th, 2019 - Wyn Staheli, Director of Research
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
Answers to Your Auditing & Compliance Questions
March 4th, 2019 - Namas
National Alliance of Medical Auditing Specialists (NAMAS) hosts a forum where auditing and compliance professionals can get answers to their questions, and exchange information with other professionals across the country. Recently, we've received the following question regarding fracture care that we'd like to share below. Q: I recently noticed CPT 26600, ...
Understanding NCCI Edits
February 20th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
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 ...
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
February 14th, 2019 - Aimee Wilcox
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
Charging Missed Appointment Fees for Medicare Patients
February 7th, 2019 - Wyn Staheli, Director of Research
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
Are HIPAA Changes Coming?
December 18th, 2018 - Wyn Staheli, Director of Research
On December 14, 2018, the Office for Civil Rights (OCR) issued a Request for Information (RFI). They are considering making changes to some of the HIPAA regulations. Earlier this year at the HIMSS (Healthcare Information and Management Systems Society) meeting, Roger Severino, the head of the Office for Civil Rights ...
Medicare Advantage Providers are not Required to be Enrolled in Medicare
December 18th, 2018 - Wyn Staheli, Director of Research
There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to ...
Keeping Up to Date
December 7th, 2018 - NAMAS
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...
Errors Billing Outpatient Services When Patient is also Inpatient
November 29th, 2018 - Wyn Staheli, Director of Research
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance: Medicare Inappropriately Paid Acute-Care Hospitals for ...
No Good Deed Goes Unpunished
November 28th, 2018 - Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA
You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.
Q/A: Does My LMT need an NPI? How do I Bill Her Services?
October 22nd, 2018 - Wyn Staheli, Director of Research
Question: I am setting up an LMT to work as employee under Dr. Clifton, DC. i need to know several things - hoping they are related and can be grouped into this one question.... does she need her own NPI? where does that NPI # go? what box #? if not, ...
We've Always Done It This Way and Other Challenges in Education
October 19th, 2018 - BC Advantage
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...
Q/A: Do I Have to Accept Any New Patient?
September 24th, 2018 - Wyn Staheli, Director of Research
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?
Join QPro Today and Get Certified
September 12th, 2018 - Find a Code
Join QPro Today and Get Certified! To have a credential in the medical profession shows you have met a minimum standard for professional and ethical standards. Often employers prefer to hire staff that will be involved with any type of patient information such as coding, to show proof they have met certain ...
Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
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...
Q/A: Is it Legal to Shred Archived Patient Records After a Certain Amount of Time?
August 3rd, 2018 - Wyn Staheli, Director of Research
Shredding patient records. When is it appropriate? Read more to find out.
WHO Said ICD-11 is Coming Soon
June 26th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
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 ...
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
June 18th, 2018 - Wyn Staheli, Director of Research
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
Medicare Claim Submission Exceptions
June 18th, 2018 - Wyn Staheli, Director of Research
There are several exceptions to the Medicare "Mandatory Claim Submission Rule." What are they?
Home Oxygen Therapy -- CMN for Oxygen
June 14th, 2018 - Raquel Shumway
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.
The Range of Motion Conundrum
June 7th, 2018 - Gregg Friedman, DC, CCSP
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
Q/A: Am I Supposed to List the Frequency and Duration on the ABN?
May 22nd, 2018 - Wyn Staheli, Director of Research
How to fill out Box D (Services) on the ABN form. What information is required?
Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?
May 7th, 2018 - Wyn Staheli, Director of Research
A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?
Q/A: Should I be Using Modifier 96 on PT Claims?
April 30th, 2018 - Wyn Staheli, Director of Research
As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?
Q/A: Someone Broke into My Office. What do I do Now?
April 23rd, 2018 - Wyn Staheli, Director of Research
My office was broken into last night. I use electronic health records, but we do store some protected health information for my patients in paper files. These files are not secured, so the burglars did have access to them. It did not appear that the files were touched as the burglars were looking for cash. What responsibilities to I have to my patients in a situation like this? Do I need to contact them and advise them that their PHI could have been compromised?
Scoring & Reporting Your Audit Findings
February 2nd, 2018 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
Are Your Computers Vulnerable to Cyber Attacks?
February 1st, 2018 - Wyn Staheli, Director of Research
Healthcare providers must be vigilant in ensuring that software upgrades, also known as patches, are kept current. Failure to do so can lead to a HIPAA Security Breach with all its associated penalties. For example Windows XP no longer has security updates and should not be used in healthcare settings. On ...
Traumatic Subluxation Coding Controversy
February 1st, 2018 - Wyn Staheli, Director of Research
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 ...
Two of the Largest Public-Private Health-Care Forms a New Partnership.
February 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS announced today, “VA, Health and Human Services Announce Partnership to Strengthen Prevention of Fraud, Waste and Abuse Efforts”.   This new alliance will allow the VA access to CMS’ program integrity protocols which will enable them to close existing gaps in their claims payment process. CMS stated in the announcement today, “CMS ...
Creating a Culture of Compliance in 2018
January 26th, 2018 - Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC
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....
Compliance: What is it and Why is it Important
January 22nd, 2018 - Joan S. Hartman, RHIT
Compliance. It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important?
What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?
January 18th, 2018 - Brandy Brimhall, CPC CPCO CMCO CPMA QCC
What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?
MIPS - To Participate or Not Participate - That is the Question
January 10th, 2018 - Wyn Staheli, Director of Research
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
OIG Advisory Opinion Recinded - Lessons Learned
December 21st, 2017 - Wyn Staheli
In the compliance world, it is important to know when the OIG makes an advisory opinion on a subject. For example, the advisory on Time of Service or Prompt Pay Discounts helps to ensure that providers are creating policies and procedures which will meet the standards of the OIG in the case ...
Does an Informed Consent Really Matter?
November 27th, 2017 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Yes, it does matter! A lack of informed consent could possibly be considered any of the following, misconduct, crime, medical malpractice, negligence or battery. The concept of using an informed consent began around 1972, in 1992; the U.S. Supreme Court ruled that informed consent laws are...
So, How Do You Decide if a Service was Provided?
October 13th, 2017 - David Glaser, JD
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.....
Chart Auditing For Beginners
August 11th, 2017 - Michelle West, CPC, CEMC, CPMA, CRC
In the new year, have you found yourself in the new role of performing internal chart audits for your organization? Are you often finding yourself saying "Now What?!" First, take a deep breath and start with the basics. In this week's tip, I will review the very basic tips and ...
Compliance Program - What are the Requirements to Implement an Effective Program?
August 1st, 2017 - Christine Taxin
All sponsors are required to adopt and implement an effective compliance program, which must include measures to prevent, detect, and correct Part C or D program non-compliance as well as FWA. The compliance program must, at a minimum, include the following core requirements: 1. Written Policies, Procedures, and Standards of Conduct; 2. Compliance Officer, Compliance Committee, ...
Password Tips
July 31st, 2017 - Wyn Staheli
How secure are your passwords? What is your organization doing to protect itself from unauthorized access?
Health Care Fraud - Don’t Do It!
July 31st, 2017 - Chris Woolstenhulme, CPC, CMRS
If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this.  I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...
Penalties Under the False Claims Act Have Risen for the Second Time Within the Last 12 Months
June 30th, 2017 - Robert Liles, JD, MBA, MS
The False Claims Act is the primary civil enforcement tool utilized by the U.S. Department of Justice (DOJ) to address false claims submitted to government programs and contracts by individuals and entities. The statute was first passed during the Civil War in 1863 in an effort to address the wrongful ...
Getting Serious About Your Practice’s Compliance
June 30th, 2017 - Jesse Overbay, JD
By now, hopefully most (if not all) practices know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan for most of this decade. In its own words, the OIG believes "that a healthcare provider can use internal controls to ...
Risk Adjustment Calculator
May 25th, 2017 - Chris Woolstenhulme, CPC, CMRS
Risk Adjustments are used to access an illness or severity and comparing classifications of diseases using diagnosis codes. Find-A-Code gives you the ability to search for risk codes used for calculations on an individual code or calculator for a group of codes to quickly calculate a risk score. Keep in mind prior ...
The Office of Inspector General (OIG)
April 14th, 2017 - Chris Woolstenhulme, CPC, CMRS
The Office of Inspector General (OIG) has the responsibility to identify and detect fraud, waste, and abuse for the United States Department of Health and Human Services (HHS) (also known as the Health Department). The mission of the U.S. Department of Health and Human Services is to enhance and protect ...
Office of Inspector General (OIG) - Compliance Program Guidance
April 14th, 2017 - Chris Woolstenhulme, CPC, CMRS
The compliance program guidance documents are listed below. 09-30-2008Supplemental Compliance Program Guidance for Nursing Facilities (73 Fed.Reg. 56832; September 30, 2008) Compliance Program Guidance for Nursing Facilities (65 Fed. Reg. 14289; March 16, 2000) 11-28-2005Draft Compliance Program Guidance for Recipients of PHS Research Awards (70 Fed.Reg. 71312; November 28, 2005) NSTC Launches Government-Wide Initiative ...
Emergency Preparedness Final Rule
February 23rd, 2017 - Wyn Staheli
Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs). There are specific standards for each of the named types of providers ...
OSHA Compliance
January 23rd, 2017 - Wyn Staheli
OSHA is a requirement for healthcare offices. Here are a few basic tips and links for helpful information.
DOJ Announces $4.7 Billion in False Claims Act Recoveries: But What Does That Really Mean?
December 30th, 2016 - Paul Weidenfeld
The Department of Justice (DOJ) recently announced that it had recovered $4.7 billion in False Claims settlements and judgments making it the "third best year" in "False Claims Act History." Trumpeted by many as a return to DOJ's record setting years, an examination of the numbers over time reveals that ...
December 20th, 2016 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
This handy FAQ addresses the uses and mis-uses of the ABN form.
Health Risk Assessment
December 13th, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...
60 Day Final Rule
December 12th, 2016 - Wyn Staheli, Director of Research
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling overpayments for both Medicare and Medicaid takes effect. Failure to report and subsequently return an overpayment within 60 days after the overpayment was “identified” is a violation of the False Claims Act.
December 7th, 2016 - Wyn Staheli, Director of Research
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...
Medical Billing and Coders Professional Liability
November 29th, 2016 - Find-A-Code
Companies who regularly handle such sensitive information as patient medical records have a particular responsibility to maintain the confidentiality of the data. Failure to exercise the appropriate degree of care – whether intentional or not – can have a significant adverse financial impact on your firm. The Federal Health Insurance Portability ...
IRFs: Final FY 2017 Payment and Policy Changes
August 16th, 2016 - Find-A-Code
On July 29, CMS issued a final rule (CMS-1647-F) outlining FY 2017 Medicare payment policies and rates for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP). CMS is updating the IRF PPS payments for FY 2017 to reflect an estimated 1.65 percent ...
History of Present Illness
August 5th, 2016 - Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
Per Medicare's 1995 and 1997 documentation guidelines, "HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present." The History of Present Illness (HPI) is the story that explains the progress of the condition ...
Security Risk Assessment Wizard - are you at risk?
August 4th, 2016 - Chris Woolstenhulme, CPC, CMRS
Attention:  Any Any healthcare organization that stores, transmits or maintains PHI (Protected Health Information) in electronic formats is required to adhere to the HIPAA Security Rule... see if your organization is at risk with security compliance. Visit for a Security Risk Assessment (SRA) Tool complete with training and other guidance to ...
Medicare’s Readmission Penalties Hit New High
August 4th, 2016 - Jordan Rau
The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show. The government will punish more than half of the nation’s hospitals — a total of 2,597...
Family meetings without the patient present
December 29th, 2015 - Codapedia Editor
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 physician to discuss the patient's care. The...
Pre-op visits: True or False?
December 29th, 2015 - Codapedia Editor
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery. • The...
Cloned E/M notes
December 29th, 2015 - Codapedia Editor
Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note? Well, Medicare contractors have noticed the same thing, and the Office of Inspector General has included this on their 2011 Work Plan. Medicare contractors have...
How soon after a visit must the documentation be complete?
July 27th, 2015 - Codapedia Editor
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...
Modifier 25
July 27th, 2015 - Codapedia Editor
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for...
Can we bill a low level E/M with every procedure?
June 1st, 2015 - Codapedia Editor
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. ...
Consult Documentation Guidelines
September 3rd, 2014 - Jeannie Cagle, BSN, RN, CPC
By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...
OIG adds to increased scrutiny of how patients pay for rising share of drug costs
May 27th, 2014 - Scott Kraft
Charity programs that help patients pay for the rising cost-sharing obligations of needed drugs may run afoul of anti-kickback rules when the charity’s scope is so narrow that it guides the patient toward specific drugs for treatment or providers, the HHS Office of Inspector General said last...
OIG Work Plan to look at excessive patient billing, place of service errors
February 9th, 2014 - Scott Kraft
The 2014 OIG Work Plan has finally been released and, while it doesn’t have a lot of new issues for physician practices, there are definitely some areas worth your attention to avoid future compliance hassles. If you’ve been wondering where it’s been, the OIG decided to change...
CMS clarifies the ways physician practices can respond to additional documentation requests
October 25th, 2013 - Scott Kraft
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...
EMRs - Coding and Compliance Concerns
April 24th, 2013 - Allison Singer, CPC
Introduction The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...
OIG Work Plan 2012
April 2nd, 2012 - Codapedia Editor
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New ABN form mandatory Nov 2011
March 15th, 2012 - Codapedia Editor
An Advance Beneficiary Notice (ABN) is a written communication given to a patient prior to providing a service that informs the patient that Medicare may not or will not cover the service. It is required when the service is sometimes, but not always, covered. If the service is never covered...
Preparing for RAC expansion
January 18th, 2012 - Betsy Nicoletti
The Recovery Audit Contractor Initiative was a CMS demonstration project whose purpose was to identify overpayments from the Medicare Trust Fund and return those overpayments to Medicare. CMS hired private contractors in three states to do this. CMS found the program to be wildly successful,...
September 18th, 2009 - Charlene Burgett
In an attempt to make the ABN more understandable for my physicians and staff, I developed this explanatory paper that is specific to our office; however, the basics apply to all offices. Charlene Burgett,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPM Administrator, North Scottsdale Family Medicine POMAA...
Minimal E/M service on an established patient
August 10th, 2009 - Codapedia Editor
Nurse visits are services provided by nursing staff in a physician office under the general supervision of a physician. The physician does not typically have a face-to-face service with the patient. These services are billed with code 99211. The CPT® book defines 99211 as: Office or other...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
Will the RACs audit E/M services?
April 14th, 2009 - Codapedia Editor
This is the $10,000 question: will the RAC auditors, now in place throughout the country, look at E/M services? Here is what CMS says in its FAQ on the topic: From their website: Will the Recovery Audit Contractors (RAC) review evaluation and management (E&M) services on physician claims...
Recovery Audit Contractors (RAC)
April 4th, 2009 - Codapedia Editor
Medicare's Recovery Audit Contractor Initiative started as a demonstration program, mandated the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). It began in three states, was expanded to New York, Massachusetts, Florida, South Carolina and California and ended on March...
E-Prescribing and Medicare Bonus Payments
April 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE Question Our doctors want to begin e-prescribing in order to get the Medicare bonus payment. How much is the bonus payment, and how do we let Medicare know that we are e-prescribing? Answer The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...
Compliance Plan for Small Physician Practices
March 30th, 2009 - Codapedia Editor
In 2000, The Office of Inspector General released a Compliance Plan for Small Physician Practices. Although it is not mandated, the OIG "recommended" that physician practices implement a Compliance Plan. There were seven components listed: Standard of conduct Compliance...
Sample size and selection for a coding audit
March 30th, 2009 - Codapedia Editor
In 2001, the OIG published a compliance plan recommendation for physician practices. This is one in its series of compliance plans: hospitals, labs, billing services, etc had already been published. A copy of it from the Federal Register is attached in the resource page. In it, the OIG...
Retrospective audits
March 29th, 2009 - Codapedia Editor
Many physician practices took the OIG recommendation to heart, and do annual compliance audits. There are many questions to answer about audits: how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or...
Prospective audits
March 29th, 2009 - Codapedia Editor
Many physician practices took the OIG recommendation to heart, and do annual compliance audits. There are many questions to answer about audits: how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or...
Encounter form content: all codes in a category
March 29th, 2009 - Codapedia Editor
When we design paper encounter forms, (or select the frequently used codes for the favorites in an electronic charging service) we face two conflicting demands. On the one hand, we want to have as many codes as possible on the form, to give the practitioners as many options as possible. On the...
Facility versus non-facility in the Physician Fee Schedule
March 26th, 2009 - Codapedia Editor
The Medicare Physician Fee Schedule has values for some CPT® codes that include both a facility and a non-facility fee. The facility fee is typically lower. When CMS develops the fee schedule, each code has three components: work Relative Value Unit (RVU), practice expense RVU and...
Ventilator management
March 18th, 2009 - Codapedia Editor
There are two codes for ventilator management for inpatient services: 94002 and 94003. One is for the day when the physician initiates vent management and the second is for a subsequent day. They are mutually exclusive codes in the CCI edits and may not be billed together on the same day. See the...
Documentation Time Limits
March 12th, 2009 - Codapedia Editor
How soon does a clinician need to document the service after performing the service? If you are asking this question, it is probably because a physician or other clinician in your practice is behind in documenting their encounters. Here is what CMS says in the Claims Processing: (Publication...
Can I bill for coumadin management over the phone?
March 10th, 2009 - Codapedia Editor
A physician asks: "Can I bill for coumadin management for patients in the nursing home? I sometimes get 25 calls a month with PTINR results, and have to make decisions about the patient's coumadin dose. Can I bill for that?" Unfortunately, no. Medicare considers this part of the pre...
Can a Physicians Assistant do a consult?
March 9th, 2009 - Codapedia Editor
This question comes up at seminar after seminar. Someone says, "My billing manager told me that PAs (or NPs) can't do consults. Is that true?" It is a half truth. PAs and NPs may perform consults, as long as consults are in their state scope of practice. They may perform consults on...
Advance Beneficiary Notice
March 3rd, 2009 - Codapedia Editor
The Advance Beneficiary Notice (ABN) form was revised by Medicare in April of 2008. There are no longer two forms available, one for lab and one for other services; there is a single form. Starting March 1, 2009, all physicians must use the new form. When completing the ABN, the practice should...
Medically Unlikely Edits
February 28th, 2009 - Codapedia Editor
Medicare developed a set of edits that it has instructed carriers, fiscal intermediaries, DME processors, and now Medicare Administrative Contractors (MACs) to follow. This edits were developed in addition to the National Correct Coding Initiative Edits to keep the payers' claims processing systems...
OIG Work Plan
February 9th, 2009 - Codapedia Editor
Every year, the Office of Inspector General releases a Work Plan for health care services, in October. The Work Plan describes the areas of interest that the OIG will investigate in the coming year. There are sections for hospitals, nursing homes, and of course, physicians. There are usually...

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