1. L

    Question What are the legal and reimbursement repercussions of incorrect dx codes?

    Our practice has recently changed the method that claims are sent out. Currently the providers chose the level and the dx codes 😟. Biannual auditing of the providers was put in place. Coders are not allowed to make changes to the submitted level or submitted dx codes. Coders add modifiers as...
  2. K

    Wiki Coder liability in timely documentation

    Does anyone have insight or resources in relation to the liability that falls on a coder when a provider submits documentation weeks/months after a visit occurred to be coded? Conversation came up that I could potentially start receiving documentation from however long ago a provider decides to...
  3. J

    Wiki OIG Audits of high risk diagnosis groups

    In recent audits of Medicare Advantage plans, the OIG has included codes for lung, breast, prostate, and colon cancers. In the report, they state that many of the cancer codes were not supported because the patient "did not have surgical therapy, radiation treatments, or chemotherapy drug...
  4. B

    PT requesting to void some claims

    Hi All, Can anyone give me some guidance or references if a patient can come back requesting some part of their services to be voided due to high deductibles so they can be self-pay? I know they can opt-out, but is it okay after the fact and to do so for one specific service and not others...
  5. lindsey.motter

    Wiki CPCO or ...

    Good morning :) I accepted a role within my company, and will be working with HEDIS/STARS compliance. Would the CPCO exam be appropriate, or is that more auditing related?
  6. G

    Wiki Chiropractic Physician, CPC-A, MCS-P (Compliance Specialist)

    I am seeking full time employment in coding, auditing, and compliance work. I have practiced Chiropractic (Family practice, portal of entry) for 23 years, I have been a Compliance Specialist and Officer for my practice for 3 years, and a newly minted CPC-A. lastly, I am a post-graduate...
  7. T

    Wiki NPP Nurse Practioner Licensing

    Is it within Licensing Guidelines for a NPP (PRNA) to interpret & sign off on 51798 PVR Bladder Scan (technically a radiology code) when NO Physician in office performed by back office (LPN/MA) for diagnostic purposes in office? Is this something that will be denied in an audit and is it...
  8. jeremyf90

    CPCO (Passed June, first try) - Looking for a healthcare compliance job.

    Hello all, Title says it all. I am looking for a healthcare compliance job - and I am open to relocation! I am a Juris Doctor, and have experience in assisting Fortune 500 companies with their regulatory compliance issues. While I do have experience in HIPAA privacy breach matters, I do not...
  9. A

    Wiki Small Doctor's office wants to recommend insurance policy to patients

    So, like the title says, the issue I am facing is that the doctor who own this office wants to get Patients to switch insurance. My assumption is that we are legally not allowed to do something like that. Ethically it seems clearly wrong. Apparently the Doctor is trying to avoid having to switch...
  10. L

    Wiki Multiple Claims in 1 Day

    I'm taking over the Compliance portion for a small Dermatology Office. Right now the provider will submit MOHs on one claim, but then submit the biopsy on a different claim that gets signed off a week or more later. And another provider will chart and bill for the closures. This is causing...
  11. K

    Premade Template Guidelines

    I've got a provider that has built templates for specific insurances. While templates aren't a bad thing, the way these are built are greatly concerning. The template looks like a complete document with prebuilt HPI, ROS, Exam, Assessments, and Procedures. Essentially, the visit looks complete...
  12. K

    Question When is a pre-built Template taking it too far?

    I have a provider that has a pre-formatted template that looks like the entire note is complete with already generated diagnoses and labs/procedures. Absolutely nothing prompts entry by the provider and it's a complete note with HPI, ROS, Exam and A/P. This is a data integrity issue but I'm not...
  13. emeskina

    Wiki Coding all documented conditions...

    ICD-10-CM coding guidelines instruct coders to accurately capture secondary dx as documented/addressed by the provider in the body of their note and A/P to the highest specificity. We are also instructed to code all documented conditions that co-exist at the time of the encounter/visit AND...
  14. C

    Coding and billing from incomplate records

    I am questioning the legality and ethical propriety of coding and billing medical procedures from the doctor's handwritten notes on the patient's hospital facesheet. In this situation, the doctor is recording the date, the procedure and Dx description for hospital inpatients on the patient's...
  15. C

    Coding and billing from incomplete records

    I am questioning the legality and ethical propriety of coding and billing medical procedures from the doctor's handwritten notes on the patient's hospital facesheet. In this situation, the doctor is recording the date, the procedure and Dx description for hospital inpatients on the patient's...
  16. A

    Wiki 90696 for patients outside of 4-6 years old

    Hello, The nurse at our clinic who administers vaccines sometimes admins a 90696 for kids outside of the 4-6 age rage. She says it's due to patients being behind on their vaccines and circumstances like that. Can I code this a a DTaP 90700 and IPV 90713 separately? Or do I have to use the...
  17. L

    non-credentials NPs billing under credentialed NPs

    Are there any other organizations billing one NP's service under another NP's name and NPI? We have new mid-level providers who aren't yet credentialed, so the established mid-level providers in the clinic are signing the notes and expecting the claims to go out under their name and NPI...
  18. K

    Wiki new medicare advantage rules 11/1/2018

    I'm curious as to what other's reactions are to the new MA RADV auditing rule proposed on November 1, 2018. What do you believe it means to compliance professionals and how does this fit into the existing structure for the MA program as you already understand it. What do you think it means and...
  19. K

    seeing patients without ID

    Where I work we are allowed to check in patients without picture id providing they are cash pay. It concerns me that we are creating medical records and writing prescriptions for these patients. Do I have reason to be concerned or should I just relax?
  20. A

    physician privileges??

    Having a conversation with a friend who works for a different company about their P&P's. She believes that ER physicians can perform procedures anywhere in the hospital. It is my understanding it should be laid out in the credentialing/privileging process or med staff bylaws. So I'm just...
  21. H

    Physician, Coder Issues

    I am wondering if any one knows where to find a document that you can have your physicians sign, stating that they are liable for any billing issues, such as fraud etc. I was told at a Medicaid conference you can have your physicians sign one. I only want one because I am told alot to just bill...
  22. D

    Wiki NP seeing patients without physician on site

    Can a nurse practitioner see patients in a family practice office where the collaborating physician does not see patients and is not on site ever? Can the NP bill under the physician's name for those plans that do not recognize NPs? This is in the state of Florida.
  23. O

    NP in Credentialing Process

    Can anyone give me some advice on if we are in compliance by allowing our NP who is in the process of being credentialed(apps already submitted) to see the patients on her own without the provider going in the rooms with her but who is readily available to answer any questions she may have...
  24. C

    HIPAA timeframe for completing documentation for an encounter

    This may be an unusual question, but I'm hoping someone out there can guide me to the answer. The provider at my clinic is from a much older generation. As such, he has been rather slow to embrace EMR and relies heavily on his handwritten notes when examining patients. After the encounter, the...
  25. A

    Seeking remote compliance opportunities

    Hello, I am a compliance consultant seeking opportunities. If you are interested in filling a senior compliance role please email me at Thank you!
  26. W

    FQHC billing/services question

    Hello- I am writing from a clinic that is about to merge with a FQHC look alike. We will begin billing under the FQHC look alike's status and will receive the PPS rate for eligibile visits. Probably not necessary to say, but I have questions around what this looks like from a billing &...
  27. D

    Looking for opinions on capsule reading and billing global

    Good Afternoon All, If a provider is buying the capsule cams, has the download center equipment and is paying someone to read their capsule but then reading it themselves and signing the note that the provider read the test; would this be allowed in order to bill globally? I was told if the...
  28. M

    Need some serious advice for serious issue!

    During a routine maintenance of computer systems I.T. stumbled upon highly sensitive company communications going on via an employees personal, third party email account. Based on the nature and content of the emails that had popped up on the home screen, I.T. felt they had probable...
  29. S

    Wiki Downcoding Lab Services

    We are an independent lab. Humana and Cigna now have policies in place that they will not reimburse any higher than a G0480 tox for Humana and a G0481 tox for Cigna. What Cigna does is downcode when they reimburse and Humana pays the higher tests than recoups a couple months later and we have to...
  30. K

    What constitutes a patients medical record?

    At the clinic where I work when vaccines are given they are recorded online in a state registry but nowhere within our EMR. I have been told that the state registry is a part of the patients medical record and therefore that is sufficient documentation. But since we don't maintain that registry...
  31. C

    Grant funding vs Using insurance

    Hello, I work for a nonprofit mental health center that accepts insurance but is largely funded by grants. I am having a hard time getting straight answers from our contracted payors (insurance companies) so I am looking for some guidance to balance grant funding for services where the client...
  32. R

    Wiki Ethical Coding and Billing

    Question. I have noticed that a practice is billing incident to incorrectly. They are billing under the physicians numbers (thus receiving reimbursement at a higher rate). The NP and PAs are seeing new patients and the doctor has never seen the patient at all. I have brought this to their...
  33. J

    Wiki HELP! Anesthesia - 7 Minute PACU Rule

    Hello, I was wondering if anyone knew the exact publication or compliance guideline set forth by CMS that talks of the general assumption that the anesthesia care team should only need 7 minutes for PACU turnover after a procedure. I already put in a request with CMS but then received the...
  34. U

    Incident To

    Practice I work for is bringing on a provider (MD) who is licensed in New York moving to Illinois. As we await credentialing, we were looking to bill incident to for this MD under the attending (IVF Clinic) . We understand the rules for the E+M and treatment plans to be managed by the...
  35. D

    Reasons for attending Healthcon? Supervisor inquiry

    In order to attend Healthcon my supervisor requires a statement on how my continued education will benefit the company. I would love to read others reasons for attending prior to submitting my application.
  36. P

    Wiki Toxicolog Laboratory Billing

    Hi All, I was wondering if anyone knew the legality of billing a screen and a confirmation under 2 different Tax IDs. This is for a Toxicology Laboratory.
  37. L

    Wiki correcting documentation before claim submitted

    I code hospital billing and I have a provider who has an intern following him, recently he has allowed the student to document handwritten progress notes and he signs over them correcting/adding/ inputting his own MDM, however the note doesn't have anywhere documented that the intern wrote it...
  38. K

    Wiki What are the rules regarding inactivating patients in your EMR?

    Can anyone direct me to where I can find info regarding whether it is or is not permissible to inactivate a patients chart and how long you have to wait to do this? I know that (in my state at least) if you haven't seen a patient in three years they are no longer considered your patient. But if...
  39. D

    Question for you Gastro billers out there!

    Hello All, I wanted to get some opinions on a few things: 1. If my doctor sees a patient prior to colonoscopy screening and the patient is there to just go over the colonoscopy steps and sign consents. Are we able to charge for this visit? I have seen where it states if just there for a...
  40. A

    Wiki CPCO Certification - course through AAPC

    Hi all, To whom already certified as CPCO, or planning to take the CPCO, how do you plan or already passed the certification? What kind of courses are you taking? Did you pay for the $1500 ($1200 on sale until 3/31/2016) for the course through AAPC? If so, how much did that help you with the...
  41. M

    Compliance Interview? What to expect?

  42. K

    Procedure 99188 and 99401

    Our physicians want to offer to our patient's dental evaluations and dental varnish in our office at same time they are doing a well check. The dental services would be for children 3 and under and for patient's who have a commercial insurance. Procedure codes are 99188 and 99401 dx Z41.8. We...
  43. T

    Wiki Compliance violation

    I have an incident that violates our compliance program. What is the best way to write this up? Is there a form of some kind? This is the first time a violation has occurred so it needs to be addressed so that the compliance committee is aware of what has happened to take action and try to...
  44. P

    Wiki Ethics & Compliances Coding Specialist - UTMC

    Ethics & Compliance Coding Specialist - UTMC Ethics and Compliance Coding Specialist University of Tennessee Medical Center The University of Tennessee Medical Center is the region’s only academic medical center, Magnet® recognized hospital and Level I Trauma Center. The 581 bed hospital also...
  45. J

    Opening for CPCO to Be SME for HIPAAInstitute - New from SuperCoder

    Dear AAPC Members, is hiring for its latest online software and services products in compliance offered by We are hiring a CPCO who has at least five years of experience as a compliance office for a physician practice. The position will serve as the subject...
  46. S

    E/M MDM Table 1: Self limiting/minor vs. New Problem

    I have been an auditor for several yrs and have never considered a self limiting or minor problem as a New Problem on the Med Dec Making Table of Risk (Table 1) # of Dx or Management Options. In my opinion and due to the fact that there is a separate box for self limiting (1 pt), it would need...
  47. J

    Consult versus H&P

    Does anyone know of any documentation <CMS> where it explains that even if a physician is called to the ER for a consultation if he/she ends up admitting the patient to their service it is coded as an H&P. My docs want the reimbursement for the consults v H&P and I need something in black and...