Documentation audits: Comprehensive listing of medical codes used to describe medical procedures and services. It is regularly updated to reflect changes in medical practice and technology. When coding for pain management procedures, it is important to accurately document the specific procedure performed, as well as any associated diagnoses or conditions. This documentation should include a detailed description of the procedure, the anatomical location involved, any devices or equipment used, and any complications or additional services provided. New codes introduce and documentation requirements.​

Documentation requirement and coding : ​

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.​

Understand your physicians documentations and their procedures CPM (Chronic Pain Management – monthly bundled codes)​

Treatments require an injection of medication injected into a certain site; locations for this include joints, tendons, or nerves, etc​

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Procedure performed: Trigger point injections, Joint aspiration, Nerve blocks, Chronic care management (CCM) services, etc​

Other Frequently Used Pain Management : Acupuncture, Radiofrequency ablation (RFA) . Medicare rolled out new codes 2023 including bundled care, evaluation and management, telecare visits and more.​

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As needle placement aspects can have a significant effect on the codes, accurate documentation is essential to assign the right codes.  With a wide array of codes to describe various diagnostic and therapeutic procedures and references to injection location, coding pain management procedures in-depth understanding of insurance coverage, diagnosis for which treatment was done and procedure selection. Diagnosis requirement: Comprehensive list of pain codes are available, understanding acute and chronic conditions and location are crucial. Selecting the most accurate code that describes the patient’s condition. For example, if a patient presents with low back pain, the appropriate ICD-10-CM code would be M54.5 (Low back pain). However, if the patient has a more specific diagnosis such as lumbar disc herniation or spinal stenosis, a more specific code should be used

Viaante has experience and expertise in the medical billing and coding procedures which enables us to deliver high quality and accurate results on time. Our experienced team of AAPC, CPC, and CPC-H certified coders, with expertise in CPT, ICD 10-10, HCPCS Level 3 and DRG codes. We specialize in Internal Medicine, Radiology, E&M, Inpatient Hospital Coding, ER Hospital Coding. Our team of experts have in-depth knowledge and all the necessary expertise to guide you throughout the process and provides you with the best possible solution. We adapt to industry standard practices, technology, quality audit procedures and different medical software to enhance execution of on-time billing and collections.

Our coding services reduce chances of rejection and ensure seamless settlement of claims. Our workflow is organized and provides an optimum result. Viaante believes in providing the best possible services to our esteemed clients and patrons. Our operations comply with HIPAA. We also provide onshore/offshore subject matter experts. We are committed to reducing errors in the system with our efficient medical coding solutions. Our medical coding program have a considerably better turnaround time with utmost accuracy.

Documentation audits: Comprehensive listing of cancers diagnosis codes frequency alerts,  multiple procedure cci edits is crucial for Urology procedures and services. Keeping eye on regularly updated to reflect changes in medical practice and technology.  It is important to accurately document the specific procedure performed, as well as any associated diagnoses or conditions. This documentation should include a detailed description of the procedure, and multiple surgery (leading to) performed at same session, with complications or additional services provided. New codes introduce and documentation requirements.​

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The range of codes used are 50010 through 58294 and addition codes from radiology series. Appropriate use for appending modifier – “Rt/Lt or 59/XS”, avoiding over use of 59/ XS modifier.​

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The types of surgeries billed for Urology include –Transplantation; Catheter Introduction; Cystoscopy, Urethroscopy, Cystourethroscopy, etc. Time for surgery and any complication resulting the increase of surgery time, required documentation in detail about the difficulties occurred during the surgery.​

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Importance:​

To train providers on documentation needs and completeness of medical records ​

Fear of audits leading to under coding,  which leads to loose of revenue, this also leads to skewed data pattern, which would lead to red flag for Medicare.​

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Diagnosis: Diagnosis description of appropriate ICD-10-CM, with appropriate laterality. example- “ R31.9 – Hematuria” what kind of hematuria the patient is experiencing and capturing code specificity. Avoiding unspecified diagnosis codes is crucial, example “C67.9- Bladder cancer unspecified”.

Documentation audits: Documentation should include specific of technology used apart from  general surgical documentation and treatment or disease and disorder urinary track conditions.. Importance of combination diagnosis is crucial, example CKD – providers should document the underlying condition whenever possible like Hypertension/ Diabetes.​

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The types of surgeries billed for Nephrology include for Procedures performed for condition chronic kidney disease (CKD), acute kidney injury (AKI), glomerulonephritis, kidney infections, kidney stones, electrolyte imbalances, and hypertension (high blood pressure) related to kidney problems- Dialysis Services; Kidney Transplantation; Biopsy Procedures; Interventional Procedure etc. Time for surgery and any complication resulting the increase of surgery time, required documentation in detail about the complication occurred during the surgery.​

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CPT Range – The range of codes used are 50200-50389 and other surgeries, 90935-90947, 74176-76775, etc.​

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Importance:​

To train providers on documentation needs and completeness of medical records along with technology use (robotic surgery, etc)​

Fear of audits leading to under coding,  which leads to loose of revenue, this also leads to skewed data pattern, which would lead to red flag for Medicare.​

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Diagnosis: Diagnosis description of appropriate ICD-10-CM, with appropriate laterality. example- “ CKD, ” what stage, any other comorbidities or underlying condition for capturing code specificity. Avoiding unspecified diagnosis codes is crucial, example “C67.9- bladder cancer unspecified”.