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Category Archives: documentation
Ready or not…ICD 10 is coming
CMS has announced that there will be no more delays in ICD 10. Come October 1, 2014, ready or not everyone will be required to use ICD 10 diagnosis codes in order to get reimbursed for services performed on or … Continue reading
Posted in Coding, compliance, documentation, EHR, guidelines, Healthcare, ICD-10, Uncategorized
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AMA Errata Revised 01/25/2013 – Changes in Psychotherapy and Prolonged Services
AMA released a revision to the 2013 CPT Manual Errata dated: 1/25/2013 – 2:03:37 PM. The changes for Psychotherapy is with CPT Code 90837 Psychotherapy, 60 minutes; the parenthetical that states to use of the Prolonged Services for psychotherapy services … Continue reading
Posted in Coding, CPT, documentation, E/M, Uncategorized
Tagged AMA, errata, prolonged, psychotherapy
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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.
Posted in Coding, documentation, Documentation, EHR, Medicare, Miscellaneous, Uncategorized
Tagged CMS, medical records, recordkeeping, transmittal
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Service Wide Review Results for IPPS Claims for DRG 311: Angina Pectoris
Novitas Solutions conducted a 50 claim service wide post pay probe review for Diagnostic Related Grouping (DRG) 311: Angina Pectoris. The review ensures that services billed to Medicare are covered, are correctly coded, and are reasonable and necessary. This review … Continue reading
Posted in CMS, documentation, Medicare, Uncategorized
Tagged Angina Pectoris, CERT, DRG, iPPS, J12
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Major Overhaul Coming to Mental Health Coding Effective January 1, 2013
The psychiatry section of CPT was restructured to incorporate new coding concepts to accurately reflect the difference in work performed by psychiatric and mental health professionals. The new series of codes capture the dramatic changes in the way psychotherapy services … Continue reading
Posted in Coding, CPT, documentation, E/M, Practice Management, Uncategorized
Tagged psychiatry
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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
Posted in CMS, documentation, Documentation, EHR, Healthcare, MAC, Medicare, Practice Management, Uncategorized
Tagged CMS, EHR, electronic health record, MAC
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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
Posted in CMS, Coding, documentation, Documentation, E/M, Medicare, OIG
Tagged audits, CMS, E/M, OIG
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WPS: Status of 3 chronic conditions accepted with 97 guidelines only
E/M documentation Here is a follow-up article, to a prior blog post, that was reported by Karen Long of Part B News Practices that followed WPS carrier instructions to document extended history of present illness (HPI) with three or more … Continue reading
Posted in Coding, CPT, documentation, E/M, MAC, Medicare
Tagged 97 Guidelines, Chronic Conditions, E/M, HPI, Part B News, WPS
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