Recent HIPAA Privacy updates and the 21st Century Cures Act’s Information Blocking rule have left offices completely confused about what they can and cannot do regarding medical record requests.
Hot Topics from the KMC University Helpdesk | October 6, 2021
As usually happens, once the annual coding update occurs on October 1, more clarifications and myriad questions continue to circle. Now that our members have been using the codes, we have unraveled several other things that are important based on questions to our Helpdesk. Listen and KMC explains what we’re finding, and finally…which new lower back pain code should you use… if any at all!
Did you know that KMC University prescribes active episodes of care for offices?
With increases in HIPAA safeguards, many practices were misguided in believing they could not have a simple sign-in sheet. There are rules, but there are also permissions. Make sure you know what to ask and use your sign-in sheet compliantly.
A written policy is imperative to the success and compliance of professional courtesy. Do you know how you would respond to someone on a professional courtesy that has a car accident? What about your staff? Are they on a professional courtesy policy? Learn what it takes to be compliant!
Maintenance care is priceless for a patient's well-being. We know the value of the care long term for the patient. But what do we charge during maintenance? Maintenance has a cost for the patient; make sure you are charging them compliantly. Take a moment and check your written policies to make sure you have included this topic.
There are specific coding requirements for Clinically Appropriate care that must be followed. Don't fall in the trap of billing Medically Necessary codes for Clinically Appropriate care.
Are you writing a best-selling novel when documenting within the episode of care? Are you capturing the information along the way to show proper progression and therapeutic benefit of the services performed?
Re-evaluations are necessary to prove the continued medical necessity of the care. Keep in mind that payers have enhanced claim edits for separate and distinct service modifiers such as -25 and -59. Every time they delay your payment, they are making more money. The key is knowing individual payer policies and learning how to fight the denials effectively.
We have all lost something at some point in time. Losing function is often overlooked by the patient as “normal.” However, it is not normal, and to create documentation of an initial visit of an episode of care, the doctor must establish what function that patient has lost.
We frequently find providers overbilling the 98943 when extraspinal adjustments are part of their philosophy and protocol. Likewise, we find some providers are not billing 98943 when the documentation supports the service. Let's learn when and where to use 98943 when adjusting areas outside of the spine.
Do you find yourself forgetting to change box 14? Have you ever changed box 14? Let's learn when and why to change box 14 while considering certain situations when you do not use the first treatment date of THIS episode of care
Many people have service animals, while some have hand guns. While we worry about the safety and our concern for all of our patient and staff, what do you do when someone wants to bring something extra along?
One area repeatedly missing in the documentation of a treatment plan is established short-term and long-term goals. Did you know that you are much more likely to reach your goals if you write them down? There are tools available to help you establish these essential pieces of initial visit documentation.
Staying clean is imperative to good health just as clean notes are imperative to proper documentation. Properly using the right kind of SOAP on every visit can ensure the integrity of your notes. Know "What" you are doing and "Why" you are doing it. Keep it clean.
Five thousand doctors in Illinois have received a letter from the Special Investigations Unit regarding outlier coding and billing.
Ever hear this, “It just started hurting Doc, nothing happened!”? Something happened, and to properly document medical necessity and bill a third-party payer, there must be a mechanism or injury.
While magic disappearing acts are fascinating to watch and often leave you intrigued, the disappearing patient not only leaves you wondering what happened but at risk when you don't stick a pin in it. What is "it"? The episode of care. Don't have a dangling participle. Instead, bring the patient's last visit closer to the end of the episode of care and put a pin in it.
According to MultiState Information Sharing & Analysis Center (MS-ISAC) an advisory was released in late May and again on June 14th for iOS users about an exploit that may have already impacted devices
Did you realize there are rules regarding how long you have to document for a visit? Not only are there time limits, but you also cannot bill for services not written. Timely documentation = timely payment. If you are feeling overwhelmed, let us help.