Skip to content

Top 10 Documentation and Coding Issues for Physician Practices in 2021

Make sure you are addressing these top documentation and coding compliance concerns.

  1. Risk-based review of evaluation and management codes (E/M):
    1. Appropriate application of FY21 E/M code guideline changes
    2. Telehealth visits (audio and visual vs. telephone only); Medicaid behavioral health telehealth
    3. Review providers with higher than 10% of visits in level 4 and 5, or outliers on E/M bell curve
    4. Level 4 and 5 visits with only one diagnosis code
    5. Conduct highly productive provider analysis (review visits per day outlier)
    6. Appropriate use of prolonged and critical care services codes as well as time-based codes
  2. Appropriate use of Modifiers
    1. High risk modifiers: 25, 57, 59 (including XE, XP, XS, XU)
    2. Other modifiers to focus on: 24, 58, 62, 63, 76, 78, 80, AS
  3. Incident to services (appropriate reporting of NPP services and split-shared services)
  4. Teaching physician and supervising physician services
  5. Coding and reporting co-morbidities for coverage of routine foot care (meeting specificity in the LCD, use of modifiers Q7, Q8, Q9)
  6. Wound care (especially debridement services 1104x, 97597)
  7. Copy/Paste documentation (ensure documentation is unique for the visit and presenting complaints)
  8. Chart review for documentation of active treatment and specificity of chronic conditions to support HCCs
  9. Advanced Care Planning Services – ensure appropriate clinical documentation to support face to face services and/or time spent discussing ACP services
  10. Data mining to identify trends/outliers (e.g. conduct top billed procedure analysis, identify and follow up on trends in claim denials)