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Everyone wants to bill better but staying up with regulations and changes on the healthcare landscape make clean documentation and billing a moving target. This month we focus on how to improve the accuracy of your documentation with information provided by the National Committee for Quality Assurance (NCQA). We’ll also cover what’s happening with payers and regulators. Some prominent payers are taking actions to discourage the use of E/M modifier 25 by reducing payments and requiring additional documentation. In the meantime, federal auditors are focusing on COVID fraud and assessing a wide range of urgent issues — from health disparities to vaccine administration to nursing home oversight and preparedness. Read on for more information.

Better Documentation Boosts EMR Accuracy

Not only is technology an important factor in keeping your medical records on track, but it can also help enhance patient engagement — and your bottom line.

According to the National Committee for Quality Assurance (NCQA), the organization responsible for the Healthcare Effectiveness Data and Information Set (HEDIS) performance improvement tool, “Current, consistent, and complete documentation in the medical record is an essential component of quality care.”

If you need help to ensure you’re on providing the quality of care that is recommended by NCQA, these tips can help boost your documentation skills and electronic medical record (EMR) accuracy.

Build a foundation for better documentation

A good first step is understanding the “commonly accepted standards for medical record documentation” according to the NCQA. The NCQA guidelines highlight six of 21 elements (listed below) “as core components to medical record documentation.” Most would agree that these elements are central to good medical record-keeping.

  • Significant illnesses and medical conditions are indicated on the problem list.
  • Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
  • Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
  • Working diagnoses are consistent with findings.
  • Treatment plans are consistent with diagnoses.
  • There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

See the full NCQA guidelines.

Tips to stay consistent, current, and complete

1. Be Consistent

Let your EMR help you stay consistent by turning on functionality that allows you to view the author of a note (physician, scribe, medical assistant, scribe, or another clinician) by entry. This will make it easier to monitor and ensure consistency across all visits and all charts.

This is consistent with one of the other NCQA guidelines that suggests “All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier, or initials.”

Take a further step toward consistency by creating a template for follow-up care, calls, or visits that includes specific time frames.

2. Stay Current

Even though this is not explicitly stated in the NCQA guidelines, it’s easy to forget details without a timely sign-off on the record. This is a significant and widespread problem according to experts and can leave practices wide open to problems down the road.

This echoes the sentiments of the Centers for Medicare & Medicaid Services (CMS), which notes “the service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record,” (Medicare Claims Processing Manual Chapter 12, Section 30.6.1(A)).

CMS guidelines are not specific about a timeframe for signing off, but to stay current, a 24-48 sign-off is a smart timeframe that ensures clinicians don’t forget to include important details of a patient encounter. Additionally, you should also look to state guidance and requirements for the timely authentication of medical record documentation, as some states provide those requirements.

3. Be Comprehensive

Document important details that could affect decision-making, such as allergies, medical history, and significant medical conditions. These details should be noted prominently.

In other words, the record should be as scrupulous as possible documenting the first three bullets of the NCQA’s core components to medical record documentation, which tell you to document all significant illnesses and medical conditions and include a thorough and easily found patient history that includes not just past conditions but pertinent conditions that are not present in the patient’s past, family, and social history.


Modifier 25 Under Attack

Modifier 25 is overused in the industry and has been under scrutiny from payers for decades. It appears that payers are reacting to this misused modifier with new policies to discourage use.

Correct use of Modifier 25

Every procedure has an evaluation built into it. Modifier 25 is used to indicate a significant, separately identifiable evaluation and management (E/M) service was required on the day of a minor surgical procedure. The procedure performed must have a global period of 0 or 10 days.

Documentation to use modifier 25 should show the amount of work performed is more than the level of effort normally performed with the procedure. When pricing minor surgical procedures, a small level of evaluation is included.


  • Appropriate use: A patient presents with severe pain in the right knee. The evaluation determines the patient has arthritis and the decision is made to perform a large joint injection. This procedure has a 0-day global period which means any E/M performed on that same date is included in the injection procedure. Modifier 25 should be appended to the E/M since the procedure was unplanned.
  • Inappropriate use: The same patient cannot get the injection on that date. They plan to come back the next day for a planned injection. There is no change in their condition. The decision to perform an injection was already done the day before. A separate E/M, and thus modifier 25, should not be reported with this planned procedure.

Private payers are currently implementing new policies to push back on Modifier 25.

As of 08/01/2022, Horizon will pay E/M services with a 25 modifier at 50 percent of their allowable if a minor surgical procedure is reported on the same date. See the announcement at

Cigna has decided that effective 08/13/2022, when practices bill a minor surgical procedure with an established E/M code, records will be required at the time of submission. This was announced via letter to in-network provider. At this writing, their reimbursement policy has not been updated. The policy can be found at

Experity will continue to monitor these and other payer policies.

Feds Double Down Scrutiny of COVID Fraud

If you thought healthcare fraud enforcers primarily focused on upcoding and unbundling, think again. The reality is that the HHS Office of Inspector General (OIG) is always looking for issues to investigate, and a new report suggests COVID-19-related fraud and abuse are now its prime target.

Background: The OIG reports on fraudulent and abusive healthcare behavior that impacts federal healthcare programs in its Semiannual Report to Congress. The agency’s most recent report focuses on incidents, enforcement, and takedowns from Oct 1, 2021, to March 31, 2022, with COVID-19 a central proponent of the enforcement spotlight.

“OIG continues to prioritize work related to COVID-19 response and recovery. With 70 audits and evaluations underway, assessing a wide range of urgent issues — from health disparities to vaccine administration to nursing home oversight and preparedness, among others — and the issuance of fraud alerts, OIG continues to advance the four goals that drive OIG’s strategic planning and mission execution with respect to HHS’s COVID-19 response and recovery,” notes Inspector General Christi A. Grimm in the report. “These goals are to: (1) protect people, (2) protect funds, (3) protect infrastructure, and (4) promote effectiveness of HHS programs, now and into the future,” she adds.

Statistics: During the report timeframe, OIG highlights great strides made through audits, enforcement, and recoveries while working in tandem with its partners at the Department of Justice (DOJ), State Medicaid Fraud Control Units, and other federal, state, and local law enforcement. Here’s a breakdown of the report numbers:

  • Audits: OIG released 47 audit reports and 14 evaluations. It expects to recover more than $1.14 billion from its audit work. The agency also questioned more than $1.6 billion in costs, too.
  • Investigative recoveries: OIG anticipated its investigative recoveries at $1.44 billion during the reporting period.
  • Criminal actions: The federal watchdog brought criminal actions against 320 individuals and entities.
  • Civil actions: OIG levied civil actions against 320 individuals and entities.
  • Exclusions: The feds excluded 1,043 individuals and entities from federal healthcare programs over the time period.

Critical: OIG’s focus on COVID was a major factor in its report, particularly related to Medicare. The agency points to an alarming increase in COVID testing that ran adjacent to a marked decrease in non-COVID testing for Part B beneficiaries, highlighting that the feds spent $1.5 billion on COVID-19 tests in 2020, but only $1.2 billion for other tests during the same period. “In total, laboratory spending increased by 4 percent, but the decrease in utilization of non-COVID-19 tests raises concerns about potential impacts on beneficiary health,” warns the report.

View the full report.

Industry Notes

Cigna: Future Claim Denials

Cigna plans to implement a new Unacceptable Principal Diagnosis Codes Reimbursement Policy on 08/13/2022.

Principal diagnosis” is a concept for inpatient admissions. It is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”. Within the ICD10 tabular list, codes that should not be used as a principal diagnosis are identified as “unacceptable principal diagnosis”. Per the new policy, if an unacceptable principal diagnosis is the only diagnosis code used, the claim will deny.

Why is this a problem for us?

Both Z23 (encounter for immunization) and Z20.822 (exposure to COVID) are unacceptable primary diagnoses.

The policy has been delayed twice.  Experity will continue to monitor. Read the new reimbursement policy at

Payer Record Requests for Post-Payment Review

Insurance companies are busy doing post-payment reviews to recoup money.  Usually requests for records are sent to the physical address of the practice.  They are usually over 10 pages long with the majority being a list of patients.

Be on the lookout for letters from payers. These requests have deadlines. Failure to send records by the deadline has resulted in large refund requests. Don’t waste time. Respond quickly to payers to avoid unnecessary financial repercussions.

New York Workers Compensation Claims

Effective July 1, 2022, the New York Workers’ Compensation Board (NY WCB) is requiring all workers’ compensation claims be submitted on a CMS-1500 claim form with a medical narrative to both the workers’ comp carrier and the NY WCB.

The goal of this initiative is to increase health care provider participation in the work comp system and improve injured workers’ access to timely, quality medical care, as well as reduce the administrative burden of time-consuming paper forms.

As a requirement of this initiative, providers must complete registration on the NY WCB Medical Portal to obtain an NY WCB Auth Number. The estimated turnaround time for approval is one business day per the NY WCB.

For more information, ask your Client Success Manager at Experity.

New Telehealth Place of Service Codes

At the beginning of 2022, the Centers for Medicare & Medicaid Services (CMS) implemented a new place of service (POS) code 10 for telehealth services to indicate the patient location (i.e., distant site) was the home. Medicare updated their system to accept this POS as of April. Other payers are now following their example.

At this time, this POS has no impact on reimbursement. It is informational only. POS 10 was loaded in the Experity system when announced so it is available for clients to start using.

Interested in more urgent care tips, best practices, and industry updates? Check out our April and June installments.

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