In Coding
Dec 22nd, 2015
Delivering toys to children around the world in one day can take its toll. View Santa’s condition after last year’s voyage and how the professionals (elves?) at the North Pole Medical Clinic treated him. Santa gave his permission to share his chart. HIPAA regulations were followed in the creation of this graphic. Infographic: Santa’s Medical Chart ...
In Audit
Jul 15th, 2015
by John Verhovshek, MA, CPC As a coder, you should always review the provider’s entire progress or operative note to be sure no reportable services are missed. Improper code selection also may result if you code from documentation headers instead of reading the note in its entirety. For example, the operative report header report may ...
Jun 30th, 2015
By Jaci Johnson-Kipreos, CPC, COC, CPMA, CPC-I, CEMC It is nice to be nice. Even with audit findings. Sometimes, at the completion of an audit, I look at the spreadsheet of findings and see that there are none. The provider did an excellent job and all codes were appropriately documented. Should the spreadsheet go out just ...
Apr 21st, 2015
Diana Williams, BS, CPC, CCS-P, CCS, CPMA CMS is aware that amendments, corrections, and delayed entries occur in the medical record. Occasionally upon review, a provider may discover that certain entries, related to actions that were actually performed at the time of service, were not properly documented or entered after rendering the service. Whether a ...
Brevity is an effective approach to letting providers know documentation must support services. Valerie Milot, BS, CPC, CCS Last November, the Centers for Medicare & Medicaid Services (CMS) released its revised Evaluation and Management Services Guide. In reviewing the document, I was reminded of how easy it is for any of us to get so ...