Audits/Auditing - Articles

Understanding the Changes to the 2023 Evaluation & Management (E/M) Definitions for Chronic Conditions
November 15th, 2022 - Aimee Wilcox
This will be the third time since 2021 that the diagnosis complexity definitions have undergone significant changes. The initial 2021 changes were specific to Office and Other Outpatient E/M services and due to some confusion surrounding a few of the guidelines, updates to them were published by the AMA in April of 2021 with an effective date of January 1st. Because the 2023 E/M changes are more focused on the remaining E/M categories, especially in the hospital facility, new definitions were added and old definitions changed.
How Does the Definition of "Problem Assessed" Change in the 2023 E/M Guideline Updates?
November 1st, 2022 - Aimee Wilcox
The 2023 Evaluation and Management changes have been published and efforts are ongoing to educate coders and provider organizations on the guideline and code description changes that will impact professional coding in the facility setting. These changes required a significant revision to the guidelines and definitions of the various levels of complexity associated with the Number and Complexity of "Problems Addressed" during an encounter, which is the first element of medical decision making (MDM) and the following explanations and examples should provide a greater understanding of the changes headed our way in January.
Tighten Up Your Laceration Repair Coding Skills
October 24th, 2022 - Aimee Wilcox
One of the most common procedures performed in the ED or physician's office is a simple laceration repair, so why is it that these simple procedures are often coded incorrectly or not even reported? It's time to tighten up your laceration repair coding skills, and ensure these are reported right and never passed over again.
Is the Patient Truly Ill? Why Random Audits Could Prevent Recoupment
October 24th, 2022 - Ronald Hirsch
Three items are discussed in this article: First, performing random audits of critical care visits billed with CPT codes 99291 and 99292 to ensure the patient was truly critically ill, which could help avoid recoupment. Secondly, time will tell if rural hospitals will switch to the rural emergency hospital designation. Lastly, a 2023 OPPS proposed rule, CMS discusses creating a new payment category, paying for software as a service.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
AHIMA Releases New Guidelines for Queries
October 11th, 2022 - Chuck Buck
The updated guidelines were developed jointly by AHIMA and ACDIS. The American Health Information Management Association (AHIMA), in collaboration with Simplify Compliance’s Association of Clinical Documentation Integrity Specialists (ACDIS), jointly announced a highly anticipated preliminary update to their Guidelines to Achieving a Compliant Query Practice on October 10,...
More Audits and More Problems
June 30th, 2022 - Ronald Hirsch
More audits are coming, how do we stay compliant? We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers...
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...
Opportunities to Identify Risk Adjustable Chronic Conditions Expands in 2022
April 26th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare made changes to the rules governing concurrently reporting transitional care management services and chronic care management services during the same calendar month. How might this help providers identify chronic conditions that risk adjust?
Preventive Services
April 26th, 2022 - Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...
Audit News Exacerbates Healthcare Crisis
March 24th, 2022 - Ronald Hirsch, MD, FACP, CHCQM, CHRI
No good news is not good news. Last week brought some news that may have significant financial consequences for many providers. The Health Resources and Services Administration (HRSA) program that funded care for uninsured patients with COVID-19 will run out of money and stop accepting claims on March...
Coding for a Performance of an X-ray Service vs. Counting the Work as a Part of MDM
March 21st, 2022 - Stephanie Allard , CPC, CEMA, RHIT
When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was...
Continuous Glucose Monitoring (CGM) Systems: Leveraging Everyday Tech to Enhance Diabetes Management
March 16th, 2022 - Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer
However, is the coding for the treatment and management of diabetes being adequately captured? Diabetes mellitus (DM) affects over 400 million people worldwide. It is a chronic disease of inadequate control of blood levels of glucose that affects the body’s ability to turn food into energy. Essentially, the...
Medicare Auditors Caught Double-Dipping
March 14th, 2022 - Edward Roche, PhD, JD
Overlapping extrapolations require providers to pay twice. Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount...
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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Delving Into the 360 Assessment Fraud Complaint
November 17th, 2021 - Jessica Hocker, CPC, CPB
The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.
Reporting and Auditing Drug Testing Services
November 9th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT
Drug testing is a common medical service used to manage prescription medications, verify someone is not taking illegal substances or too much of a prescribed substance, and monitor for toxicity and therapeutic dosing. It is customary for patients in treatment programs for chronic pain management or substance use disorders (SUD) to undergo random urine drug testing (UDT) or urine drug screening (UDS) as part of their individual treatment plan. Drug testing is regulated by federal and state laws (e.g., OSHA, CLIA), which must be carefully adhered to.
Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?
October 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?
ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines
October 6th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
We always knew there would come a day when payers would look down on an "unspecified" diagnosis code and possibly even deny it or delay payment until a review of the record could be performed. ICD-10-CM was adopted by the U.S. for data analytics, which cannot be accurate if unspecified codes are reported when the documentation verifies greater specificity. Join us for a look at the many guideline changes to ICD-10-CM, a review of the newest code changes and suggestions on documentation improvement to elevate coding protocols.
Is Coding Based on Addendums or Late Entries Putting You At Risk of Audit Failure?
September 30th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Independent Health, another Medicare Advantage Organization, has been named in a qui tam (whistleblower) lawsuit and enjoined by the DOJ for allegations of fraudulently upcoding to increase beneficiary risk adjustment scores to obtain higher reimbursement. It appears they used DxID, LLC, a coding consulting subsidiary of Independent Health to retrospectively identify and have providers addend unsupported diagnoses. How is your organization actively protecting against accusations of upcoding by improper use and reporting of diagnoses from provider addenda?
​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
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?
Managed Care Organizations Use CMS Tools to Identify Outliers
June 1st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Managed Care Organizations (MCOs) include risk-adjusted plans whose funding is based on the health status of their beneficiaries. Government-funded MCOs use CMS information to search for suspected cases of fraud and abuse.
OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment
May 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
58% of Improper Payments due to Medical Necessity for Ventilators
April 29th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?
April 19th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
April 12th, 2021 - Wyn Staheli, Director of Research
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
The OIG Turns their Gaze to Possible Inpatient Service Upcoding
March 17th, 2021 - Jared Staheli
The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...
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?
Are NCCI Edits Just for Medicare?
July 14th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
Packaging and Units for Billing Drugs
May 18th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number. Take a look at the following J1071 - Injection, testosterone cypionate, 1mg For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL (100 mg/mL = 1 mL and there are ...
A 2020 Radiology Coding Change You Need To Know
February 10th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
CPT 10-Year Historical Content - Now Available!
January 22nd, 2020 - Find-A-Code
Did You Know? We now offer Historical CPT Content in 2-year, 5-year, or 10-year options! Utilize access to specific CPT historical data for previous years using rules effective at that specific time. If you’ve added UCR fees to your account, you can use Historical CPT Content to view UCR fees from ...
Denials due to MUE Usage - This May be Why!
January 7th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
What did I do today?
December 13th, 2019 - Namas
What did I do today? Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...
And Then There Were Fees...
November 11th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
October 18th, 2019 - Namas
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
Medical ID Theft
August 16th, 2019 - Namas
Medical ID Theft "So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
The Slippery Slope For CDI Specialists
August 2nd, 2019 - Namas
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 ...
Tips to Preventing Audits
July 23rd, 2019 - Christine Taxin
There is an ever-increasing number of dental claims that 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 billing practices. When payers identify the activities they deem ...
Helping Others Understand How to Apply Incident to Guidelines
July 5th, 2019 - Namas
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
A United Approach
June 14th, 2019 - Namas
A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
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 ...
What to Look for When Auditing Smoking Cessation Services
May 24th, 2019 - NAMAS
What to Look for When Auditing Smoking Cessation Services
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 ...
What is Medical Necessity and How Does Documentation Support It?
April 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
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 ...
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. ...
The Impact of Medical Necessity on High Level E/M Services
March 21st, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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. ...
Type of Bill Code Structure (2018-08-30)
March 20th, 2019 - Find-A-Code
The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form. Type of bill codes are four-digit codes that describe the type of bill a ...
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 ...
Coding Medicare Initial Preventive Physical Exams (IPPE)
February 12th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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 ...
2018 Salary Survey
January 28th, 2019 - NAMAS
NAMAS needs your help in capturing salary information for 2018 and developing standards for the industry. This is the information that YOU as an auditor need to share with your employer! Everyone who participates will be entered into a drawing for a chance to win one of many prizes! One winner ...
How to Report Co-Surgeons Using Modifier 62
January 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
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 ...
Are You Protecting Your Dental Practice From Fraud?
January 10th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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 ...
Auditing looking between the lines
November 30th, 2018 - BC Advantage
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...
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...
Wolters Kluwer Drug Pricing
October 17th, 2018 - Find-A-Code
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...
Chiropractic OIG Audit Recommendations - Lessons Learned
September 28th, 2018 - Wyn Staheli, Director of Research
The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following: Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year ...
PSAVE Pilot Program - What Does it Mean to You?
August 20th, 2018 - Wyn Staheli, Director of Research
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
When Medical Necessity and Medical Decision Making Don't Match
August 3rd, 2018 - BC Advantage
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...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
July 18th, 2018 - NAMAS
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed. For ...
Dual Medicare-Medicaid Billing Problems
July 12th, 2018 - Wyn Staheli, Director of Research
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added): A state plan must provide ...
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 ...
Auditing Therapy Evaluation Codes - Not So Quick!
June 4th, 2018 - Nancy J Beckley, MS, MBA, CHC
New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...
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.
Developing Coding Policies for Compliance
January 31st, 2018 - Marge McQuade, CMSCS, CHCI, CPOM
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 ...
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....
Inpatient critical care: When is it ok to question the medical necessity?
November 24th, 2017 - Stephanie Allard, CPC, CEMA, RHIT
While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary.....
Fear Factor: "The Unethical Business of Medicine"
November 17th, 2017 - Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC
I want this story that I am about to share with you to fit with the majority of clients that I represent and work with because I have represented clients with refund demands as small as $1,000 and clients who had demands greater than $30 million. This year has been ...
Auditing Medical Decision Making
November 3rd, 2017 - Grant Huang, CPC, CPMA
With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....
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.....
Your NAMAS Weekly Auditing & Compliance Tip for October 6, 2017
October 6th, 2017 - NAMAS
October 6, 2017 Acronyms and Abbreviations: When You Fall Into The Grey Area 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 ...
Big Data & Facility Audit Complex Reviews
September 29th, 2017 - Shannon Cameron, MBA, MHIIM, CPC
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
Copy and Paste: The Real Rules Prevail
September 15th, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA
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.....
2017 Physical Therapy Evaluation & Management Codes
September 1st, 2017 - Kathy Price, RHIT, CPC, CCS-P, CPMA
As you know, 2017 brought us new evaluation and management codes for physical and occupational therapy....
Case Law Update: Just Because HIPAA Does Not Provide a Private Right of Action, Doesn't Mean that Other Avenues Exist
August 16th, 2017 - NAMAS
August 4, 2017 Case Law Update: Just Because HIPAA Does Not Provide a Private Right of Action, Doesn't Mean that Other Avenues Exist Simply stated, the Health Information Portability and Accountability Act (HIPAA) does not provide a private cause of action[1]. And, prior to the 2009 passage of the Health Information Technology ...
United HealthCare Ending Consultation Reimbursements: Effective October 1st, 2017
August 15th, 2017 - NAMAS
While Medicare discontinued payment allowance for consultation services (ranges 99241-99245 and 99251-99255) in January 2010, many commercial carriers have continued to cover these services. United Healthcare is now joining Medicare's opinion on consultation services. In the June 2017 edition of the United HealthCare Bulletin, United Healthcare has announced that effective October ...
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 ...
Case Law Update: Just Because HIPAA Does Not Provide a Private Right of Action, Doesn't Mean that Other Avenues Exist
August 4th, 2017 - NAMAS
Simply stated, the Health Information Portability and Accountability Act (HIPAA) does not provide a private cause of action[1]. And, prior to the 2009 passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act)[2] and the more robust chain of liability (e.g. covered entities, business associates and ...
Auditing Vaccines
July 28th, 2017 - Paul Chandler
Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding.
Don’t Overlook Diagnosis Codes During Coding Audits
July 14th, 2017 - Betty Stump, MHA, RHIT, CPC, CCS-P, CPMA, CDIP
Coding auditors focus much of their attention exclusively on C.P.T. codes during the review process. After all, codes reported for E and M visits, surgical procedures, and diagnostic services are what generate revenue to the provider or facility. Even more importantly, errors in reporting these services are frequently what give ...
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 ...
The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims
June 30th, 2017 - David Glaser, JD
This tip may contradict everything you've heard before. However, if you consider it with an open mind, you will see that it is an accurate characterization of the law, and it is also consistent with common sense. The phrase "If it isn't written, it wasn't done" is repeated so commonly ...
Auditing Neurologic Exams: Tips for Success
June 30th, 2017 - Laurie Oestreich
As an auditor, you may be asked to audit encounters that occur in various multi-specialties. It can be difficult to remember the ins and outs of each specialty, especially if you do not consistently work in a particular specialty. Neurology is one of those specialties that can appear daunting due ...
Documentation: Carrying Forward or Ineffective Use of Templates
June 30th, 2017 - Shannon DeConda
I often receive questions such as the below from our members regarding E&M scoring: "I have heard that if information is 'cloned' or 'moved forward' from a previous visit, we should not count that info in scoring. However, I have also read that if a provider moves the info forward and ...
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 ...
Focus Audit Results on the Documentation, Not the Encounter
June 30th, 2017 - Scott Kraft, CPC, CPMA
As an auditor, your job is to assess the quality of the documentation created by the provider to determine whether it meets the requirements to bill the code assigned to the service. This task often set us up a potentially adversarial role with the provider, particularly when it comes to ...
Neck: Supple
June 30th, 2017 - Shannon DeConda
I am allowed the opportunity, through our wonderful NAMAS members and bootcamp and conference attendees, to educate all walks of auditors and compliance professionals. These include not just compliance auditors and divisions in healthcare, but also auditors on the carrier side. As I do, I see the good fights on ...
Consultation or Transfer of Care, What are the Differences?
June 30th, 2017 - Dee MiMauro, CPC, COC, CPMA
According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...
Outpatient Physical Therapy Changes Effective June 13th, 2017
June 30th, 2017 - Shannon DeConda
Our friends in clinics operating in Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or in a rural area have long struggled with how to cover Physical Therapy services when a therapist is on leave, vacation, or in event of medical leave. The Centers for Medicare and Medicaid ...
Laceration Repairs
June 30th, 2017 - Michael Loss, CPC, CPMA
Auditing laceration repair is generally an adventure. Most of my auditing work is reviewing the work of our coders rather than providers, but I have audited physicians as well. My present position has limited communication with providers, however we do attempt to get important information back to our clients for ...
NGS Medicare Releases New Audit Tool
June 30th, 2017 - Liz Wilson, RHIT, CCS, CDIP, CPC, CRC, CEMC
Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years.
Focus on Clinical Documentation to Improve Coding and Audit Results
June 29th, 2017 - Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP
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 ...
NAMAS Announced New Auditing Credential!
June 29th, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA
At NAMAS, we strive to be the industry expert in auditing and compliance education. Each year, we carefully select our weekly webinar topics, annual conference sessions, and speakers to provide you with the type of training and education you need to succeed in your role. We are excited to share ...
Prescription Drug Management: Is it a Level 3 or a Level 4?
June 29th, 2017 - J. Paul Spencer, CPC, COC
If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no ...
Profit Depends on Efficiency
June 29th, 2017 - NAMAS
To us, the most fascinating thing about process improvement within a medical practice is how it has a clear clinical counterpart: differential diagnoses. In a typical scenario, a patient presents with a chief complaint ("I don't feel well"), and it's the provider's job to figure out just what is wrong ...
Think Outside the Box When Auditing Physical Exams
June 29th, 2017 - NAMAS: Betty Stump, RHIT, CPC, CCS-P, CPMA
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
To Disclose or Not to Disclose… That is the Question
June 29th, 2017 - Sean Weiss
The biggest questions I receive these days are in regard to handling potential overpayments regarding internal or external audits is whether or not the errors constitute a self-disclosure protocol. The short answer is, avoid this process unless you have verifiable fraudulent activity to report. Section 1128J(d) of the Act created ...
Auditing Incident-to Services
June 16th, 2017 - Michael Miscoe, Esq.
To effectively audit incident-to services under Medicare, the auditor must first have an operational understanding of the rule. Unfortunately, this is not as easy as it sounds. Auditors must also understand that the incident-to rule is a Medicare only rule. This is one area where the maxim "if you are ...
Insufficient Documentation Errors
March 2nd, 2017 - Chris Woolstenhulme, CPC, CMRS
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 ...
December 19th, 2016 - Wyn Staheli, Director of Research
Benchmarking is simply a standard or point of reference against which things may be compared or assessed. For all businesses, it is a way of comparing your business processes to another business in the same industry to determine where shortfalls exist or improvements can be made to maintain profitability.
International Classification of Diseases (ICD)-10 Code Updates and Impact to 4th Quarter 2016 Eligible Professional Medicare Quality Programs
December 15th, 2016 -
On October 1, 2016, new International Classification of Diseases (ICD)-10-CM and ICD-10-PCS code sets went into effect. Updating of these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support...
Risk Adjustment and Hierarchical Condition Category Coding and Auditing
December 2nd, 2016 - Michelle West, CPC, CEMC, CPMA, CRC
Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997, which was implemented in 2003. This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions ...
Don’t Undervalue Patient Complexity
August 7th, 2016 - Robin Sewell, CCS, CPC, CHTS-PW
Healthcare professionals can readily discern the acuity and severity of a patient's illness based on the presentation of the patient and objective data at their disposal. Although it is the responsibility of the clinician to convey the complexity of the case, it is not always easy for an auditor to ...
Family history--what counts
December 29th, 2015 - Codapedia Editor
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...
Not Documented, Not Done: Medicare Myth or Rule?
December 29th, 2015 - Codapedia Staff
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...
Documentation Guidelines
July 27th, 2015 - Codapedia Editor
Clinicians are still allowed to use either the 1995 or the 1997 Documentation Guidelines, whichever set is more beneficial to the clinician. Payers are required to use whichever set is more beneficial to the clinician. Some organizations have a policy stating they will only use one or the other, but that is not required by CMS or any other government payer. In fact, it is permissible to switch back and forth between the two sets of Guidelines from one note to the next.
What counts as social history?
July 27th, 2015 - Codapedia Editor
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...
99212--established patient visit
June 1st, 2015 - Betsy Nicoletti
Established patient visits all require 2 out of 3 of history, exam, medical decision making 99212: History required is problem focused: 1-3 HPI elements Exam required is problem focused: 1 body area/organ system examined from the 1995 exam, or one bullet from the multi-specialty exam or any...
Chief Complaint
March 17th, 2015 - Codapedia Editor
The Documentation Guidelines tell us that all notes require a reason for a visit or a chief complaint. This is how they define the chief complaint: The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. !DG: The medical record should clearly reflect the chief complaint.
Past medical, family and social history
March 17th, 2015 - Codapedia Editor
Rules for documenting the past medical, family and social history in an E/M note
History of the present illness
January 30th, 2015 - Codapedia Editor
When auditing an Evaluation and Management service, the history of the present illness (HPI) is one of the required components in the history section. The history of the present illness may consist of some of the eight elements described in the Documentation Guidelines or in a description of the status of the patient's chronic illnesses. Joan Gilhooey reminds physicians to add some adjectives when their HPI comes up short.
Review of Systems
January 30th, 2015 - Codapedia Editor
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...
It’s a home health crackdown, but your phone’s going to ring
August 5th, 2014 - Scott Kraft
Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care. Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to...
Yet another new auditor looking at Part B claims
August 5th, 2014 - Scott Kraft
Recovery Audit Contractors (RACs) may be about to take a break while CMS awards new contracts, but don’t rest on your laurels. CMS has handed out yet another auditor contract for a single auditor, known as a Supplemental Medical Review Contractor (SMRC) to do nationwide claims reviews for...
CMS puts the brakes on RAC audits for now, and implements changes for when they return
April 30th, 2014 - Scott Kraft
Good news for physician practices that don’t like getting demand letters and record requests from Recovery Audit Contractors (RACs). All those requests will stop by Feb. 28 on orders from CMS. RACs will be back once CMS awards new RAC contracts, but those awards may not come soon. When they...
CMS looking for ways to boot providers who don’t correct repeated billing problems
January 30th, 2014 - Scott Kraft
Providers with a history of making the same mistakes over and over again may find themselves on the outside of the Medicare program looking in, if CMS has its way. The agency has formalized a policy to use existing regulations to identify these providers and be able to issue civil monetary penalties...
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...
Hospital Observation Services
August 28th, 2013 - Dorothy Steed
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary....
Why Get Into Medical Billing?
March 22nd, 2013 - Debra Sanders
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over 15 yrs and still learn something new every day. I even learn something I...
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...
Do headings matter in an E/M note
March 30th, 2009 - Codapedia Editor
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical,...
Do you need three vital signs for it to count?
March 4th, 2009 - Codapedia Editor
This is one of the most common questions physicians and NPPs ask at coding conferences. Do I need to document three vital signs for it to count. It depends on which set of guidelines the clinician is using. For 1995, no. Any one vital sign or general appearance counts for constitutional. For...
Comprehensive exam, 1995 Giudelines
March 4th, 2009 - Codapedia Editor
A comprehensive exam using the 1995 Guidelines requires eight organ systems. You may not count body areas. The Guidelines do not give any definition about how much must be examined in each system, and auditors typically count anything within that system. The Guidelines say, Comprehensive -- a...
Auditing the exam 1995 Guidelines
February 11th, 2009 - Codapedia Editor
Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. ...
Interval History
February 9th, 2009 - Codapedia Editor
Some CPT® codes require an interval history. This article defines an interval history.

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