- alyaya on Meaningful Use Attestation Records & Documentation Retention
- Brian Moseley on 2012 Physician Fee Schedule Policy & Payment Changes
- Dusty on New Enrollment Form Could Curb Referral-related Denials
- Luis Elvers on EHR Attestation Begins April 18. Are You Ready? Are You Registered
- Mack Penhall on CMS Adopts Policy and Payment Changes for Outpatient Care in Hospitals and Ambulatory Surgical Centers
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Category Archives: Documentation
Connecticut PCP Pays $700k to Settle False Claims Act Allegations
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
CMS Updates Amending & Correcting Medical Record Documentation
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.
DHHS and DOJ Issue Warning On Potential EHR Misuse
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.
RAC Audits are Coming to Physician Practices!
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.
EHRs: Friend or Foe?
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
Proper Documentation of Plan of Care – Chiropractic Services
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
High Level E/M Codes are Coming Under Increased Scrutiny by the OIG
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
Documentation Guidelines Interpreted Differently Based on your MAC
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