May 26, 2023 | By Stephanie Allard, CPC, CEMA, RHIT Most of us, if not all of us, have heard the statement, “If it isn’t documented, then it wasn’t performed.” While I know this is often the perspective of payors, I cringe when I hear this, thinking about all the providers that I work…
July 1, 2022 | By Stephanie Allard, CPC, CEMA, RHIT After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022. At the time I am writing this, there is recent news…
September 15, 2021 | By Stephanie Allard, CPC, CEMA, RHIT I am looking forward to the NAMAS 13th Annual Auditing and Compliance Conference at the Wyndham Grand Clearwater Beach on December 5th through 8th! This year, I am excited to be a part of the E&M Auditing track on Tuesday, December 7th and…
June 25, 2021 | By Stephanie Allard, CPC, CEMA, RHIT When I ask practices if they have been through an external audit recently, they typically will state “no” or let me know if recent requests for a larger number encounter notes have been received. Through these conversations, I realize that they are not noticing…
March 5, 2021 | By Stephanie Allard, CPC, CEMA, RHIT When I begin to work with a new client on an auditing project, I like to set up a meeting with them before we begin, to talk through the steps that I take as an auditor and to discuss their reason for the audit…
December 31, 2019 | By Stephanie Allard, CPC, CEMA, RHIT As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to…
May 1, 2020 | By Stephanie Allard, CPC, CEMA, RHIT Over the years I have found that one of the main risks to an organization are employees who get comfortable in their positions to the point where the explanation for or response to an audit variance is “that is how we have always…
May 15, 2020 | By Stephanie Allard, CPC, CEMA, RHIT Over the past month, I have heard comments wondering why we would continue to audit during the COVID-19 public health emergency (PHE). Many commented that with so much going on, there is not enough time, and the encounters are now telehealth so what is…
July 3, 2020 | By Stephanie Allard, CPC, CEMA, RHIT As we move towards implementing the 2021 E/M changes, we need to evaluate areas of bad habits within E/M encounter documentation. I have noticed in my current reviews that many providers are in the habit of documenting the same exact amount of…
January 15, 2021 | By Stephanie Allard, CPC, CEMA, RHIT CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like…