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Compliance - Articles

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...
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...
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?
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 ...

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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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
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 ...
ABN FAQs
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.
Discounts
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 ...
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...
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 SRAWizard.com for a Security Risk Assessment (SRA) Tool complete with training and other guidance to ...
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,...
ABN
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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