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Author Archives: cpccertification-studyguide

Navigating the laws and benefits of telemedicine

This is the first year that all 50 states have adopted some form of telemedicine coverage. Telemedicine is the remote diagnosis and treatment of patients using an audiovisual platform—a doctor’s appointment over Skype, remotely monitoring a patient’s vitals, messaging pictures of rashes and illnesses, etc. And while certain issues will still require an in-person examination (e.g., setting a broken arm), the field is opening several new options for treatment.

So why should hospitals set up a telemedicine program? And what do they need to navigate the disparate laws and regulations around telemedicine? – Briefings on Accreditation and Quality

New Proposed Rule to Reduce EHR Data Reporting

A new CMS proposed rule contains two provisions intended to reduce hospital eCQM reporting requirements in response to feedback calling for less aggressive EHR data reporting policies.

A couple provisions in a new Hospital Inpatient Quality Reporting (IQR) Program rule proposal outline modifications to electronic clinical quality measure (eCQM) reporting requirements and validation processes.

In a public document in the Federal Register, CMS proposed reductions to hospital eCQM reporting policies. In the 2017 calendar year reporting period (and 2019 fiscal year payment determination), hospitals would be required to choose six available eCQMs listed in the Hospital IQR Program measure set and offer two chosen calendar year quarters of data…


Continue reading this article


The post New Proposed Rule to Reduce EHR Data Reporting appeared first on Outsource Management Group, LLC..

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Top 4 Payer Priorities for 2016

Health Leaders Media

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  February 17, 2016 Follow us on FacebookFollow us on TwitterJoin us on LinkedInRSS feed

Top 4 Payer Priorities for 2016

Rene Letourneau, Senior Editor for HealthLeaders Media

A new payer survey offers insights for providers as both deal with a common challenge: technology. >>>


Editor’s Picks

Value-Based Care Shifts into High Gear

Guideposts for the paths to participating in value-based healthcare models come into focus at a payment innovation summit held in Tennessee. >>>

CMS Finalizes Medicare Overpayment Reporting Rule

An overpayment is considered identified by Medicare when an employee using "reasonable diligence" has, or should have, determined it was received and quantified the amount, according to the final rule. >>>

Incoming Carolinas HealthCare CEO Driven by Community, Mission

The newly named CEO of Carolinas HealthCare System, Eugene A. Woods, talks about his legacy at Christus Health and the challenges that await him when he takes the helm at one of the nation’s largest public health systems. >>>

CMS, AHIP Standardize Quality Measures

Seven measure sets aim to alleviate the burden and cost of measuring clinical quality and will "support multi-payer alignment, for the first time, on core measures primarily for physician quality programs," says CMS. >>>

Dignity Health Announces Urgent Care Partnership

The urgent care centers will be a 50/50 partnership, with Dignity Health Medical Foundation providing the clinicians, GoHealth providing the organizational infrastructure and expertise, and both entities equally sharing the capital investment. >>>

ONC: Time to Get Busy with Value-based Payment Models

"We’re in a little bit of a we-don’t-know-what-we-don’t-know state as an industry. And it’s going to dawn on people really quickly that MACRA is a really big deal," says a co-chair of ONC’s Health IT Standards Committee. >>>

The Healthcare Partnership Midrange

The middle ground of the healthcare partnership continuum is dotted with a variety of relationships that feature varying degrees of shared governance. >>>

Intelligence Report:
The Analytics Challenge—Gaining Critical Insight into Risk-Based Models

As providers undertake contracts with increasing levels of downside risk, their need for advanced analytics to manage decision making and monitor results will only grow. >>>

LIVE Webcast

Webcast: Integrating Behavioral Health: Decreasing Costs and Improving Care

Date: March 15, 2016, 1:00–2:00 p.m. ET
In this expert webcast, hear how Carolinas HealthCare System developed a strategy to optimize resources to create a truly integrated model.
Register Today >>>

News Headlines

Community Health stock slumps after surprise loss, rivals also hit

Fox Business, February 17, 2016

When a brain surgeon becomes a malpractice lawyer

ProPublica, February 17, 2016

High cost of cancer care may take physical and emotional toll on patients

The Wall Street Journal, February 17, 2016

Christ Hospital seals surgery deal with UnitedHealth Group division

Cincinnati Business Courier, February 17, 2016

Aetna gets FL insurance regulator’s approval for Humana deal

CNBC / Reuters, February 16, 2016

Cancer patients snagged in health law’s tangled paperwork

Chicago Tribune, February 16, 2016

Hacking of healthcare records skyrockets

WRCB-TV / NBC News, February 16, 2016

Top hospitals likely are available on a marketplace plan, study finds

Kaiser Health News, February 15, 2016

With end of ‘doc fix’, effort to craft a new payment system underway

The Hill, February 12, 2016

Healthcare battle brewing between governors in KY

ABC News / Associated Press, February 12, 2016

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HealthLeaders Media LIVE at NCH Healthcare System: Population Health

Date: February 23, 2016 | 11:00–2:00PM ET
In this live e-conference, discover how NCH Healthcare System has expanded its population health program with a multi-layered strategic plan.
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From HealthLeaders Magazine

Changing Patient Behavior Through Technology

Software and hardware developments are opening new ways to get patients more involved in their own care. >>>


Cancer: Aligning Costs and Care


The Healthcare Partnership Midrange

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Interstim revision

I am so confused on what codes to use for interstim revision. Doctor states explant interstim device, insertion of new device with
new quad lead of right side. Defunctionalization of existing quals lead on left side.
Complex calibration, analysis.
My co-worker says it should be 64581-50 or LT Rt and 64590. I thought 64585 Lt Rt and 64595.
Are either of us right?

Thanks Nancy

Medical Billing and Coding Forum – Urology

Pediatric Patient History – Who Can Take It?

Contrary to popular belief, it is safe practice to allow any office member to take the review of systems and the family social history. These two evaluation and management history elements can actually be taken by absolutely anyone. It is ok in medical billing for a parent or a secretary to take down this information as long as the information is reviewed and signed off on by the acting pediatrician.

The only part of an evaluation and management visit that the physician or nurse practitioner must complete for medical billing purposes is the history of present illness or the reason for the visit.

By allowing your administrative staff to complete some of the patient documentation, a practice can save time and money as it frees up the pediatricians and nurse practitioners to have more time for the actual servicing of the patients.

Another great way to save your practice time and money is to outsource your medical billing. Your medical billing partner will make sure your pediatric practice gets the maximum return and if you’re not using a medical billing company, you could be losing almost 30% of your medical billing revenue by simply not knowing how to get the maximum reimbursements that your practice is allowed for services rendered and general errors that occur when practices file their own claims.

Look into expanding the duties of your administrative staff and consider outsourcing your medical billing – the winners will be your patients and your practice!

The post Pediatric Patient History – Who Can Take It? appeared first on Outsource Management Group, LLC..

Nurses – Outsource Management Group, LLC.

Additional skin excision following mastectomy

Please help. Patient had bilateral mastectomy 2 weeks ago. Positive margin on skin. Patient taken back for additional skin excision. Doctor wants to code 19301, but the breast is gone. I’m questioning whether this should be a malignant lesion excision.

11606 -58

Any help would be greatly appreciated!


Kelly C, CPC

Indication for Surgery
left breast cancer, positive skin margin

Preoperative Diagnosis

Postoperative Diagnosis

excision left breast skin
drainage of hematoma

Estimated Blood Loss

Urine Output

The PSI-15 for accidental puncture or laceration is: none
The frozen section: none
Important intraoperative findings are as follows: old blood evacuated, more skin removed from the lateral skin flaps and reclosed

lateral skin new stitch on margin
inferior/lateral skin new stitch on margin


After informed consent was obtained patient was brought to operating room and given preoperative antibiotics and IV sedation with anesthesia. I accessed the right chest port. I removed the steris and bilateral JP drains. The left breast and axilla was prepped and draped with Chloraprep in the usual fashion and allowed the dry 3 minutes before draping. I removed the lateral skin ellipse 8 x 3 cm portion, marked. Then took another 2 cm margin on the inferior skin flap. Good hemostasis was insured and the area washed out copiously. I then placed 10F JP drain into the space from the axilla and sutured it in with 3-0 nylon. The skin was reapproximated with deep 2-0 vicryl and 4-0 monocryl sutures. Dermabond applied, sterile dressings placed, and patient was taken to recovery room in stable condition.

Medical Billing and Coding Forum – Plastic Surgery

Bolster billing compliance: Implement a Medicare Part A triple-check process

Bolster billing compliance: Implement a Medicare Part A triple-check process

Medicare billing is a domain rife with payer offshoots and evolving regulations that can be difficult to navigate without a strategy to weather claim scrutiny and withstand the gaze of CMS’ various auditing contractors.

Enter the triple-check process, a time-tested internal auditing strategy used by proactive long-term care providers to facilitate billing accuracy and compliance the first time a UB-04 claim form is submitted. As its name suggests, triple check is a layered verification process that involves staff members from billing, nursing, and therapy departments?the three core disciplines required to submit a clean claim. But this sturdy foundation is also pliable, allowing a facility to easily adapt the procedure to the various types of claims it files.

Read on for an expert iteration of the triple-check process, which is modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC. This specific triple-check procedure is designed to mobilize key staff to ensure accuracy and timely submission of Part A claims.



Each month, the SNF will collect all Medicare Part A billing information ready for submission and enlist the following individuals to carry out their designated roles in verifying the accuracy of these items: administrator, director of nursing, MDS coordinator, facility rehab director or designee, business office manager, medical records personnel, and central supply staff.

The following is a breakdown of each of these staff members’ responsibilities in the triple-check process:

Business office manager and medical records personnel

  • Verify that the qualifying stay information recorded on the UB-04 aligns with that on the medical records face sheet.


Business office manager

  • Verify that each resident has benefit days available in the HIPAA Eligibility Transaction System.
  • Verify the admit date on the UB-04 aligns with the date in the manual census log.
  • Verify covered service dates listed on the UB-04 align with those in the Medicare and manual census logs.
  • Verify that a resident’s financial file contains a signed and completed Medicare Secondary Payer form whenever applicable.


Business office manager and MDS coordinator

  • Verify that ADLs are correct and are supported by documentation. Confirm that staff have coded all other contributory items (e.g., mood, IVs).
  • Verify that ARDs on each MDS align with the occurrence dates found at form locators (FL) 31?34 on the UB-04.
  • Verify that the RUG level listed on each MDS aligns with that found at FL 44 on the UB-04.
  • Verify that the assessment type for each MDS aligns with the modifier found at FL 44 on the UB-04.
  • Verify that the number of accommodation units listed on the UB-04 aligns with the assessment type for each MDS. Verify that the total number of accommodation units aligns with corresponding covered service dates.


Facility rehab director, MDS coordinator, and business office manager

  • Verify that physical therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes documented in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that each principal diagnosis is accurate, that all secondary diagnoses support skilled care, and that every ICD-9 code corresponds to an appropriate diagnosis.
  • Verify that occupational therapy minutes recorded on the daily treatment grid align with those in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that speech therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.


DON and medical records personnel

  • Verify each resident’s need for Medicare skilled intervention by reviewing supporting clinical documentation that corresponds with the dates of service listed in the manual census log.
  • Verify that each (re)certification form has been completed and signed by the appropriate physician.
  • Verify that each physician order has been obtained and implemented.
  • Verify that each chart reflects appropriate charting guidelines. Confirm that charting has been completed at least once in every 24-hour period, relates to skilled service provided, and supports therapy.


Facility rehab director

  • Verify that physician orders include rehabilitation.
  • Verify that each evaluation notes the prior level of function.
  • Verify that clinical documentation contains a progress note establishing the need for continued skilled intervention.



  • Chair the triple-check meeting (detailed below), and ensure that the entire process is completed by appropriate staff each month before Medicare claims are submitted. Participation in the triple check will allow the administrator to monitor the effectiveness of key operational processes carried out by the facility’s ­interdisciplinary team (IDT) on an ongoing basis.

Triple-check meeting and audit tool

Each of the SNF’s triple-check participants should complete their respective duties prior to the Medicare triple-check meeting, which will be held monthly before the SNF bills for a given batch of services. In other words, the meeting is not an occasion for staff to complete their initial claim component(s). Instead, it’s a chance for IDT members to cross-check the work of their colleagues by verifying the accuracy of claim items that others have completed, thereby ensuring each element has been studied by multiple sets of eyes.

The triple-check meeting will also serve as the platform for the SNF’s business office manager to document the completion of each integral item on a billing claim using the triple-check audit tool, an internal checklist-type document that will be included in every month-end closing report.

Using this audit tool, the manager will denote items verified as correct during the triple-check meeting with an "X." He or she will mark items identified as incorrect with an "O" and, in the remarks section of the document, record the steps the team will take to obtain the correct information. Items initially found to be incorrect but rectified during the meeting should still be marked with an "O" to better track any practice patterns that could lead to billing slipups and inform future training activities.

The business office manager will call for any claim found to have errors during the triple-check meeting to be put on hold until it is amended. Once staff have made necessary revisions, the manager will indicate these correction(s) and the corresponding date(s) in the remarks section of the audit tool. He or she will then contact a corporate entity to review the changes and ultimately grant approval to submit the claim. – Billing Alert for Long-Term Care

Should a Medical Practice Join Group Purchasing Organization (GPO)?

The small and medium sized medical practice is finding its profit margin shrinking with every new compliance regulation and insurance readjustment. The opportunity to save money on the operations side may help grow a bottom line without having to levy new fees on patients or giving up office services. A group purchasing organization (GPO) leverages the power of numbers to lower prices for members without having to give up on the quality of the product.

Improving Medical Billing for Practices

EPIC Macros?

Hey everyone! Hoping someone has some kind of insight or tips.

I code for a company that uses the EPIC EMR system. We are trying to go paperless in order to start working from home. Currently, The girls that reconcile our batches to code, run a report in EPIC and have to copy and paste the information from that and create an Excel spreadsheet for us to code from. As you can imagine, this is very time consuming and with as quick as we code batches, it seems like this process is a waste. I’m wondering if there are any Macros I can run in Excel that will pull the information over in a neat spreadsheet or if there are any other tips or tricks anyone knows of that might help speed up the process or be a little easier to compile all the information.

Thanks for your help!

Medical Billing and Coding Forum – EMR/EHR Systems