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Auditing Physician Services: Verifying Accuracy in Physicians Services and E/M Coding Third Edition

Auditing Physician Services: Verifying Accuracy in Physicians Services and E/M Coding Third Edition


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Betsy Nicoletti, MS, CPC

Take the steps to audit your own practice ... before the Government or Third-Party Payer does!

New for the 3rd Edition - Overall updating of all chapters PLUS:

  • New! Auditing non-face-to-face prolonged services--now covered by Medicare
  • Updates to TCM and CCM based on new CMS rules including the initiation visit before CCM
  • New! HCPCS codes for Collaborative Care Model and Behavioral Health Initiative
  • New! HCPCS code for cognitive assessment

The key topics covered include a welcome amount of in-depth coding information - topics and activities that practices perform every week.

Protect your practice from governmental and third-party payer audits! This book explains complex reimbursement and coding rules and provides audit sheets for key, high-risk areas including E/M services.

Today, medical practices face major risks if they don’t code physician services accurately. Practices that violate the complex government regulations governing coding may face audits by the Office of the Inspector General for HHS, Recovery Audit Contractors and Medicare Administrative Contractors, and the consequences of such audits can be severe.

However, physicians and their staff now have a comprehensive guide available which helps practices audit high-risk areas themselves, before payers get involved. Auditing Physician Services: Verifying Accuracy in Physicians Services and E/M Coding To Protect Medical Practices, written by nationally-renowned coding and auditing expert Betsy Nicoletti, MS, CPC, offers critical information, support and plain-English explanations of how to avoid high-risk coding behavior.

Auditing Physician Services, provides clear, practical, concrete explanations of complicated coding issues and E/M guidelines, advice on auditing EMR notes, and a range of worksheets allowing physicians to conduct valid, defensible audits.

The book also includes a detailed analysis of the OIG Work Plan which offers insight into how the agency selects physician practices for further review.

Table of Contents

  • Medical Practice Compliance and the OIG Work Plan
  • Chapter 1: General Principles of Medical Documentation
  • Chapter 2: Aberrant Evaluation and Management Coding Patterns
  • Chapter 3: How to Audit Evaluation and Management Services
  • Chapter 4: New Patient Visits
  • Chapter 5: Consultations
  • Chapter 6: Critical Care Services
  • Chapter 7: Billing for 99211
  • Chapter 8: Incident To Billing and Shared Visits
  • Chapter9: Use of Modifier25
  • Chapter 10: Billing for E/M Services During the Global Period
  • Chapter 11: Initial Preventive Physical Examinations and Annual Wellness Visits
  • Chapter 12: Teaching Physician Rules
  • Chapter 13: Behavioral Health Services in Primary Care Practices
  • Chapter 14: Transitional Care Management (TCM) and Chronic Care Management (CCM)
  • Final Thoughts
  • Appendix 1: E/M Documentation Auditing Worksheet
  • Index
BONUS: Auditing Worksheets as you Audit Your Practice. Worksheets are available for download at the Nicoletti book website in Word Format so you can fill in the blanks!

Worksheets Include the following:
  • Chapter 1: General Principles of Medical Documentation Audit Sheets
    • General Principles of Medical Documentation--Individual Encounters
    • General Principles of Medial Documentation--Medical Record as a Whole
  • Chapter 2: Aberrant E/M Coding Patterns Audit Sheet
    • Aberrant Evaluation and Management Coding Patterns
  • Chapter 3: How to Audit E/M Services Audit Sheet
    • E/M Documentation Auditing Worksheet
  • Chapter 4: New Patient Visits Audit Sheet
    • New Patient Visit
  • Chapter 5: Consultations Audit Sheet
    • Consult Audit Sheet
  • Chapter 6: Critical Care Services Audit Sheet
    • Critical Care Services
  • Chapter 7: Billing for 99211 Audit Sheet
    • Billing for 99211
  • Chapter 8: Incident to and Shared Visits Audit Sheets
    • Incident to Test (Quiz and Answer Sheet)
    • Incident to Audit Sheet for Non-physician Practitioner Services --Established Patient Visits
    • Audit Sheet for Non-physician Practitioner Services -- New Patients
    • Incident to Audit Sheet for Nurse Visits Services
    • Shared Visit Audit Sheet
  • Chapter 9: Use of Modifier 25 Audit Sheet
    • Use of Modifier 25
  • Chapter 10: Billing for E/M Services During the Global Period Audit Sheet
    • Use of Modifier 57
    • Use of Modifier 24
    • Use of Modifiers 54 and 55
  • Chapter 11: Initial Preventive Physical Examination and Wellness Visits Audit Sheets
    • Initial Preventive Physical Examination
    • Annual Wellness Visit
  • Chapter 12: Teaching Physician Rules Audit Sheets
    • Teaching Physicians Time-Based Codes Audit Sheet
    • Teaching Physicians Primary Care Exception Audit Sheet
    • Teaching Physicians Surgical Services Audit Sheet – Minor Procedures
    • Teaching Physicians Endoscopy Audit Sheet
    • Teaching Physicians Surgical Services Audit sheet – Major Surgical Procedures
    • Teaching Physicians E/M Services Audit Sheet
  • Chapter 13: Behavioral Care Services in Primary Care Practice
    • Audit Sheet for CoCM/BHI Codes - G0502, G5403, G0504
    • Audit Sheet for Code G0507
Betsy Nicoletti

Betsy Nicoletti, MS, CPC, has extensive auditing experience in physician services, ensuring that code selection accurately reflects the services performed.

Joking that she is in the “protection” business, Betsy explains that her mission is to simplify complex coding and reimbursement rules for medical practices, thereby "protecting" physician practices. She is the author of The Field Guide to Physician Coding, now in its third edition, and Everyday Medical Coding, as well as a regular journal contributor. Betsy also speaks to groups on the national scene. When speaking to clinicians, she engages them with an in-depth knowledge of their professional lives. When speaking to fellow auditors, she guides them through the nuances of finding black and white answers in a morass of gray guidelines.

Betsy, who began her consulting business in 1999, has a master’s degree in Organization and Management from Antioch New England and is a Certified Professional Coder. She is a member of the Medical Group Management Association and the National Speakers Association. She lives in New England with her dog. Betsy can be reached at www. betsynicoletti.com. You can read her blog at www.nicolettinotes.com.

"Every practicing physician will find this book the perfect resource for documentation and coding, just as I've found Betsy Nicoletti to be the perfect resource. Nicoletti puts complicated concepts into very practical terms. Keep the book close at hand for a chapter-by-chapter reference when questions arise"

Rosemarie Nelson, MS, MGMA Consultant
Jamesville, NY

"Betsy Nicoletti understands how physicians think. This is an excellent resource for physicians and coders alike.”

William Romer MD
MediSync, Cincinnati, OH

"Working with Betsy Nicoletti for years, I know that you can rely on her advice regarding coding and auditing. She’s a pro’s pro!"

Karen Zupko, President, Karen Zupko & Associates
Chicago, IL