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Documentation Guidelines - Articles

Billing 99211 Its not a freebie
November 9th, 2018 - BC Advantage
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
Muscle Testing and Range of Motion Information
November 8th, 2018 - Wyn Staheli, Director of Research
Be sure to understand the unique code requirements for Muscle and Range of Motion Testing.
Medi-Cal Coverage Criteria for Hospital Beds and Accessories
November 7th, 2018 - Raquel Shumway
Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.
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...
Q/A: What Diagnosis Codes Should I Use for TMJ Headache Massage for Coverage?
October 16th, 2018 - Wyn Staheli, Director of Research
Question: We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as ...
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 ...
Importance of Depression Screenings
August 16th, 2018 - Wyn Staheli, Director of Research
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
Attention Providers - Please Make Time to Read this Letter
July 17th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
Documentation for Enteral Nutrition
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...
Documentation for Negative Pressure Wound Therapy
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.
Documentation for Ordering Oxygen Supplies and Equipment
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment.
Documentation for Surgical Dressings
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for surgical dressings.
Documentation for Urological Supplies
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for urological supplies.
Delivering Bacterial Culture Lab Orders
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests...
Coverage for Power Tilt/Recline Seating Systems for Wheelchairs
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems...
Documentation Tips for Ostomy Supplies
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....
Preventing Denials for Lower Limb Prosthesis
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them: For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation. For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
Preventing Denials for Therapeutic CGMs and Related Supplies
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies
Documentation and Orders for Laboratory Tests
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.
Documentation and Orders for Respiratory Assistive Device
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.
Documentation for Skilled Nursing Facilities
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).
Documentation for Inpatient Rehabilitation Facilities
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).
Documentation for Home Health Services (Part A non DRG)
March 8th, 2018 - Medicare Learning Network
The Medical Learning Network provides coverage guidance, which should be documented, for home health services.
Q and A: Coding Mixed Cardiogenic and Septic Shock
February 1st, 2018 - BC Advantage
Q: If the attending documented, "likely mixed cardiogenic and septic shock," can I assign codes R57.0 and R65.21? A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember,...
Insufficient Documentation Errors
January 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
According to CMS ICN 909160, claims are determined to have insufficient documentation errors when the medical documentation  submitted is inadequate to support payment for the services billed, meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims ...

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Lung Cancer Screening Counseling and Shared Decision Making Visit, and Annual Screening for Lung Cancer with LDCT
December 20th, 2017 - Find-A-Code
Effective February 5, 2015, a CMS National Coverage Determination (NCD) added lung cancer screening counseling and shared decision making visit, and for certain beneficiaries, annual screening for lung cancer with Low Dose Computed Tomography (LDCT), as an additional screening service benefit under the Medicare program if all eligibility criteria described ...
Auditing the Use of a Scribe
December 1st, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......
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...
Erythropoietin Stimulating Agents (ESA)
November 27th, 2017 - Wyn Staheli, Director of Research
Coverage ESA is typically covered for the following condition(s): Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis) Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS Treatment of selected ...
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.....
CMS Proposes to Revise Evaluation & Management Guidelines
October 26th, 2017 - BC Advantage
According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, ...
PFSH Documentation: Q and A
October 20th, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
Acronyms and Abbreviations: When You Fall into the Grey Area
October 6th, 2017 - Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC
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 a straight answer about whether or not it's supported higher or lower....
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....
If It’s Not a Consultation, What Is It?
August 16th, 2017 - Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported? If the payer does not support these codes If the documentation does not support ...
Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)
August 11th, 2017 - Chris Woolstenhulme, CPC, CMRS
There is important information that must be included when documenting injuries and external cause codes in ICD-10-CM. There are expanded sections on poisonings and toxins making it more convenient to code, as ICD-10-CM is very specific. When using a code from Chapter 19 (Injury, Poisoning and Certain other Consequences of External ...
Requirements for Physicians Orders for DME/HCPCS
August 1st, 2017 - Chris Woolstenhulme, CPC, CMRS
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied ...
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 ...
Diagnosing, Documenting, and Coding for Radiculopathy
June 30th, 2017 - Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP
Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in ...
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 ...
Ultraviolet Therapy
June 14th, 2017 - Chris Woolstenhulme, CPC, CMRS
Treatment of this type is generally used for patients requiring the application of a drying heat. For example, this treatment would be considered reasonable and necessary for the treatment of severe psoriasis where there is limited range of motion. Only 1 unit of CPT code 97028 is covered per date of service. Supportive Documentation ...
Documentation for Physical Therapist
June 13th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should: Paint a picture of the patient’s impairments and ...
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 ...
Documentation: Face to Face for Home Health Certification
February 27th, 2017 - Chris Woolstenhulme, CPC, CMRS
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care. Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. ...
Insufficient Documentation Errors
February 15th, 2017 - Chris Woolstenhulme, CPC, CMRS
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed - meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also ...
Pre-Existing or Gestational?
January 20th, 2017 - Chris Woolstenhulme, CPC, CMRS
It is important to make a clear distinction between pre-existing conditions and conditions brought on by the pregnancy (gestational) or pregnancy related conditions. Condition Detail: Was the condition pre-existing (i.e., present before pregnancy)? Trimester: When did the pregnancy-related condition develop? Casual Relationship: Establish the relationship between the pregnancy and the complication (e.g., preeclampsia). Code examples: O99.011 Anemia ...
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 ...
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...
99213 Established patient visit
October 15th, 2015 - Betsy Nicoletti
There are sample audited notes in resource section. 99213 is an established patient visit which requires 2 of 3 of the following components: An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed An expanded, problem focused exam, which is 6 bullets from...
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...
Medical Necessity is not Medical Decision Making
June 1st, 2015 - Codapedia Editor
I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on...
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...
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...
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: · ...
Cloned documentation on OIG radar screen in 2014
May 23rd, 2014 - Scott Kraft
One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.” Put more specifically, the OIG reports that Medicare Administrative...
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...
Modifier -24
June 21st, 2009 - Crystal Reeves, CPC, CMPE
Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not related to the postoperative care for the...
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 ...
E/M service with no exam
April 13th, 2009 - Codapedia Editor
Does an E/M service require an exam? It depends on the category of service. Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...
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,...
Is time the trump card in selecting an E/M service?
March 29th, 2009 - Codapedia Editor
Is time a trump card in selecting an Evaluation and Management service? Sometimes. Isn't that too frequently the answer in coding? If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes. The criteria are: ...
Is medical decision making a trump card in E/M services?
March 29th, 2009 - Codapedia Editor
Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient. After all, isn't a patient with a brain cancer really sick? Shouldn't that patient always be charged a high level...
Can consults be billed based on time?
March 12th, 2009 - Codapedia Editor
Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met. CPT® tells us that a physician or NPP may use time to select a code when counseing "dominates" the visit. CMS confirms these rules in their Documentation Guidelines....

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