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Sample Timed Coding Scenarios

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Documentation & Coding Curriculum | Section 2
Coding Traditional Physical Medicine
Sample Timed Coding Scenarios

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Back to Documentation & Coding Curriculum | Section 2

Documentation & Coding Basics

Why You Should Care About Documentation and Coding

8 Resources | 1 Quiz

Why Is Documentation So Important?
Quality and Purposeful Documentation and Coding
Implementing NCQA Standards
Standardized Documentation and Coding
Medical Review Policy – What Does It Mean to Me?
Locating Medical Review Policies
Coding and Documentation Concerns of the OIG
Documentation and Coding Reference Documents
Why You Should Care About Documentation and Coding

Timely Documentation

7 Resources | 1 Quiz

Best Practices for Timely Documentation
Timely Documentation
Timely Documentation Best Practice
Timely Documentation Hints and Helps
Timely Documentation in Day 1.5
Amending the Patient’s Record
Amendments-Corrections-Delayed Entries
Timely Documentation

Using A Scribe for Documentation

8 Resources | 1 Quiz

Best Practices for Timely Documentation
Proper Use of Scribes in Documentation
Know the Role of the Scribe
To Scribe or Not to Scribe
Checklist for the Use of Medical Scribes
Amending the Patient Record
Amending the Medical Record
Amendments-Corrections-Delayed Entries
Using a Scribe for Documentation

Proving Medical Necessity

7 Resources | 1 Quiz

Medical Necessity and Case Management
Defining Medical Necessity
Documenting Medical Necessity
Medical Necessity Primers
Proving Medical Necessity Can Be a Pain in the “ASH”
Medical Review Policy and Case Management
Incident, Burst or Full Episode
Proving Medical Necessity

The Patient Health Record

7 Resources | 1 Quiz

The Patient Health Record – EHR vs Paper
Standard Documentation Abbreviations
The Patient Health Record
The Anatomy of a Patient’s Chart
EHR vs Paper Documentation Comparison
PHI In All Forms
Readying Paperwork for Efficiency
The Patient’s Health Record

If it Isn’t Signed, It Didn’t Happen

6 Resources | 1 Quiz

Understanding Signature and Authentication Requirements
Signature Requirement Errors
FAQ-Medicare Signature Guidelines
Signature Self-Audit Tool
Signature Verification Form
Medicare’s Signature Guidelines Reference Documents
If it Isn’t Signed, it Didn’t Happen!

Respond to Records Requests Like a Champ

7 Resources | 1 Quiz

How Do You Respond to a Records Request?
What Do They Want From Me?
Your Amendment Rights
Reimbursement for Requested Medical Records
The Case Summary Template
Helpful Documentation Tools
Records Preparation Reference Documents
Respond to Records Requests Like a Champ

Documentation & Coding Basics Final Assessment

0 Resource | 1 Quiz

Documentation and Coding Basics Final Course Assessment

CPT Coding According to Documentation

Coding & Documentation – The Relationship

9 Resources | 1 Quiz

Documentation & Coding Guidelines
Coding Ethics – How To Choose Codes
Chiropractic Coding Terms & Acronyms
Unproven, Investigational, or Experimental Procedures
Documentation Drives Coding
The Office of Inspector General (OIG) & Compliance
Patient Acknowledgment for Non-Covered Services
Patient Acknowledgement Support Tools
AHIMA Standards of Ethical Coding
Relationship Between Coding & Documentation

Coding Chiropractic Manipulative Treatment (CMT)

12 Resources | 1 Quiz

The CMT Codes
An Overview of CMT Coding
CMT & E/M Coding
Coding Full Spine Adjustment
Coding & Documenting Primary Subluxations
Full Spine Adjusting Coding Expectations
Coding Extra Spinal Manipulation
Coding Maintenance Care
Proper Use of S8990
CMT Documentation Requirements
CMT Documentation Resources
CMT Reference Documents
Coding Chiropractic Manipulative Treatment, CMT

Coding Traditional Physical Medicine

15 Resources | 1 Quiz

Physical Medicine Documentation
Safety Focus for Therapies & Modalities
Delegating Services
Guidelines For Delegating Services
Incident To vs. Delegating Services
Documenting Physical Medicine-The Initial Visit
Documentation Samples
Documenting Physical Medicine – Routine Office Visit (ROV)
Passive Therapy Modalities
The Idiosyncrasies of Hot/Cold Packs
Timed Coding Rules
Guidelines Timed Based Codes
The 8-Minute and 15-Minute Rules
Sample Timed Coding Scenarios
Physical Medicine Resources
Documentation & Coding Traditional Physical Medicine

Coding Non-Traditional Physical Medicine

15 Resources | 1 Quiz

Non-Traditional Physical Medicine-Know the Rules
Coding for Non-Traditional Physical Medicine
An Overview of Dry Needling
Dry Needling Documentation & Coding
Acupuncture Documentation & Coding
Instrument Assisted Soft Tissue Manipulation (IASTM)
Samples: Documentation and Informed Consent
Vertebral Axial Decompression
Roller Table Traction
Hydro-Therapy Coding
Hydro-Bed Modality Coding
An Overview of Kinesio Taping
Kinesio Taping vs. Strapping
Kinesio Taping Coding
Kinesio Taping Reimbursement
Documentation & Coding Non-Traditional Physical Medicine

Coding Modifiers

13 Resources | 1 Quiz

The Magic of Modifiers
Commonly Used Modifiers Quick Reference
The 25 Modifier – Are you doing it correctly?
What is Modifier 25?
When to Use Modifier 25
When Modifier 25 is Denied
Modifying Extraspinal CMT Codes
Therapy-Modality Cheat Sheet
Fee for Time – Locum Tenens
Fee-for-Time Compensation vs Reciprocal Billing Arrangement
Billing Basics Fee For Time
FAQ Fee-For-Time Compensation Arrangements
Change Pay Policy Fee Time Comparison Arrangement
Coding Modifiers

Documentation & Coding Exercise Therapies

7 Resources | 1 Quiz

Documentation and Coding for Exercise Therapies
Coding Differences of Therapeutic Exercises – 97110, 97112, and 97530
Coding Therapeutic Exercises – 97110
Post Isometric Relaxation (PIR)
Coding Neuromuscular Re-Education – 97112
Coding Therapeutic Activities – 97530
Documentation Samples for Exercise Therapies
Documenting and Coding Exercise Therapies

Documentation & Coding Muscle Therapies

12 Resources | 1 Quiz

Manual Therapies, Play and Stay in the Game
Manual Therapy Techniques
Requirements for Billing 97140 – Manual Therapy
Muscle Therapy Documentation Samples
Documenting and Coding Massage
When is it OK to Bill 3rd Party Payers for Massage?
Muscle Therapy Codes 97124 & 97140
Instrument-Assisted Soft Tissue Therapy
Post Isometric Relaxation (PIR)
CMT and 97140 General Appeal
Massage Therapists as Employees or Independent Contractors
Massage as a Cash Profit Center
Coding Manual Therapies

Documentation and Coding of Diagnostic Testing

6 Resources | 1 Quiz

X-Ray and Imaging in Chiropractic Practice
Radiology: Rationale for Medical Necessity
Coding X-ray-Spinal and Extremities
Proper Coding for X-Rays
Full Spine X-Rays: Third-Party Bundling and Unbundling
Diagnostic Imaging Reference Documents
Documentation and Coding Diagnostic Testing

The HCPCS Code Set

12 Resources | 1 Quiz

Level 2-HCPCS Coding
The Basics of Coding with HCPCS
Level I or Level II- Which One to Choose?
Overview of Healthcare Common Procedure Coding System (HCPCS) Codes
Maintenance Care Coding
Coding for Maintenance Care
Maintenance Procedure Codes
Maintenance Diagnosis Codes
Coding for Statistical Purposes
Utilizing the HCPCS Manual
Orthotic Billing Protocols
Commonly Used HCPCS Codes
The HCPCS Code Set

CPT Coding According to Documentation Final Assessment

0 Resource | 1 Quiz

CPT Coding According To Documentation Final Course Assessment

Coding Evaluation & Management (E/M) Services

Managing E/M Updates & Changes

3 Resources | 1 Quiz

The 2021 Evaluation and Management (E/M) Changes
The 2021 E/M Changes
AMA E/M Guidelines
Overview of E/M Coding Changes

Coding According to Medical Decision Making (MDM)

6 Resources | 1 Quiz

The Three Components of Medical Decision Making (MDM)
Terms and Definitions-Medical Decision Making (MDM)
Examples of Coding E/M with MDM
FAQ-Evaluation and Management (E/M)
E/M Audit Tools
AMA E/M Tools & CMS Guidance
Evaluation and Management (E/M) Coding According to Medical Decision Making (MDM)

Coding According to Time

6 Resources | 1 Quiz

Coding E/M Appropriately Using Time
E/M Time Grid
E/M Updates & Requirements
Time-Based E/M Coding Examples
Prolonged Service Codes
AMA Summary of 2021 E/M Changes
Evaluation and Management (E/M) Coding According to Time

Coding Evaluation & Management (E/M) Services Final Assessment

0 Resource | 1 Quiz

E/M Coding Final Course Assessment

Diagnosis Coding According to Documentation

Relationship Between ICD-10 Coding & Documentation

6 Resources | 1 Quiz

Basic Documentation and Coding Guidelines
Documentation Drives Coding
The Clinical Diagnosis Process
Documentation or Diagnosis – Which came first?
Written Diagnosis Vs ICD-10 Coding in Documentation
Code ICD-10 Diagnosis with Confidence
Relationship Between ICD-10 Coding & Documentation

ICD-10 Basics

9 Resources | 1 Quiz

ICD-10 Basics
ICD-10 Coding Guidelines
ICD-10 Documentation Quick Tips
ICD-10 Chiropractic Codes Support Tool
ICD-10-Excludes Notes
Your Coding and Documentation Resources
Find A Code
MOI & External Cause Codes
ICD-10 Coding Basics Reference Documents
ICD-10 Coding Basics

ICD-10 Coding in Practice

8 Resources | 1 Quiz

Reporting Your ICD-10 Codes in Practice
From History to ICD-10 Code
Medicare Diagnosis Rules
ICD-10 Case Examples
Art of Coding from Documentation
Improving Specificity In ICD-10 Diagnosis Coding
Unspecified Diagnosis Codes
ICD-10 Coding in Practice Reference Documents
ICD-10 Coding in Practice

Diagnosis Coding According to Documentation Final Assessment

0 Resource | 1 Quiz

Diagnosis Coding According to Documentation Final Course Assessment

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