Category Archives: Documentation

Connecticut PCP Pays $700k to Settle False Claims Act Allegations

Posted on February 11, 2013 by dzetter

David B. Fein, United States Attorney for the District of Connecticut, announced on January 31, 2013, that JAMES P. RALABATE, MD, a physician, and his professional corporation, PRIMARY CARE ASSOCIATES P.C., which is located at 2890 Main Street in Stratford, … Continue reading →

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CMS Updates Amending & Correcting Medical Record Documentation

Posted on December 23, 2012 by dzetter

Medicare principles have been updated on how to amend or correct entries in patient medical records.  CMS has directed contractors to give these changes added scrutiny.

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DHHS and DOJ Issue Warning On Potential EHR Misuse

Posted on October 5, 2012 by dzetter

In a follow-up to our article from September 11, 2012, EHRs: Friend or Foe?, here is a perfect example of additional concerns about EHRs.

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RAC Audits are Coming to Physician Practices!

Posted on September 20, 2012 by dzetter

CMS communicated to the AMA on Wednesday, September 12, 2012, that it has approved the Medicare Region C Recovery Auditor(RAC) Connolly to begin conducting audits of coding for E&M services in physician offices, specifically CPT code 99215.  

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EHRs: Friend or Foe?

Posted on September 11, 2012 by dzetter

As coders and auditors, Cheryl and I have been forever warning our clients moving over to EHR (electronic health record) about cloned visit documentation for quite some time.  We now have a Medicare Administrative Contractor (MAC) that has issued a … Continue reading →

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Proper Documentation of Plan of Care – Chiropractic Services

Posted on August 28, 2012 by dzetter

Chiropractic Services (Plan of Care) Recent reviews have found significant issues with documentation for Chiropractic services. Please review these requirements for documentation.  The primary issue is that the plan of care is missing in the documentation submitted to the payer.  … Continue reading →

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High Level E/M Codes are Coming Under Increased Scrutiny by the OIG

Posted on May 31, 2012 by dzetter

The May 8, 2012, Office of Inspector General’s report, Coding Trends of Medicare Evaluation and Management Services, says payments for E/M services increased 5% more than the rate of increase for all Part B payments from 2001 to 2010 (48% … Continue reading →

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Documentation Guidelines Interpreted Differently Based on your MAC

Posted on April 3, 2012 by dzetter

There are two sets of E/M documentation guidelines. In 1995, CMS released the first set of guidelines that were tailored more towards primary care. The specialists soon spoke up, stating that under the 1995 guidelines, system-focused examinations were under-represented. Responding to … Continue reading →

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