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Welcome to the Swiftaudit blog, we’re glad you’re here! We’ve designed this page with you in mind, and we hope you’ll find our articles both useful and encouraging. We’ll share tips from our experts on how to work smarter, code and audit better, and how to find the coding job that makes you happy!

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Compliance Programs – Part 2

Though this keynote was presented in 2010, practices have seen these topics change how they operate over the last 10 years. With greater patient and caregiver involvement in care plans, innovation, and growth in use of technology, we will see greater demand for these key issues by all stakeholders in healthcare.

Some Questions Compliance Professionals Should Ask as They Prepare for Health Care Reform

Highlights of Keynote delivered by Daniel R. Levinson, Inspector General for HHS at the Health Care Compliance Association’s Annual Compliance Institute, April 19, 2010

  • Transparency: Are you prepared to operate in a more transparent health care system?
  • Quality: Are you focused on quality as a compliance issue?
  • Accountability: Is your organization prepared for greater accountability?

Fast forward to 2021, have these compliance “predictions” come to pass?

Transparency: Provisions in the 21st Century Cures Act (Cures) of 2016, prohibits Information Blocking. As of April 5, 2021, healthcare providers, HIT, health information networks or exchanges (HIN or HIE) are governed by rules and regulations regarding access to patient health information.

According to the AMA, “Physicians may implicate the info blocking rule if they knowingly take actions that interfere with exchange, access, and use of EHI, even if no harm materializes. A physician organization, for instance, may
have a policy that restricts access to patient lab results for a certain amount of time. Even if patients are not
aware there is a delay between when the results are available to the physician and when they are made available
to the patient, a practice that is merely “likely” to interfere with the access, use, or exchange of EHI could be
considered info blocking.”

Quality: There are numerous articles regarding the False Claims Act recovering millions in healthcare related fraud due to “medically unnecessary services or services not rendered as billed.” The U.S. Justice Department levied millions in fines in 2020 for not reasonable or medically necessary services / tests.

Accountability: If you google “healthcare accountability,” you will see that there are many types of accountability. There is legal accountability, patient accountability, personal accountability, systems accountability, leadership accountability, and more. CMS developed a program called Accountable Care Organizations (ACOs). ACO’s are accountable to:

  • voluntarily to give coordinated high-quality care to Medicare patients;
  • coordinate care to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors;
  • deliver high-quality care and spend health care dollars more wisely

As a compliance professional, you are part of your organization’s program to provide transparent accountable quality of care to the patients and families who count on you.

Compliance Programs

Continuing from our last post, this week we are reviewing the topics offered on the HHS OIG website in quick reads. Here are outlines of 5 documents from the OIG website.

HHS-OIG Compliance Training Materials

About OIG’s Training

OIG’s provider compliance training initiative is an outgrowth of the HHS/DOJ Health Care Fraud Prevention and Enforcement Action Team’s (“HEAT”) efforts. In Spring 2011, OIG and its government partners provided training focused on the realities of Medicare and Medicaid fraud and the importance of implementing an effective compliance program. The training focused on a  three-pronged message about provider compliance.

  • Get the Facts. Understand the law and the consequences of violating it.
  • Make a Plan. Cultivate a culture of compliance within your health care organization.
  • Know Where To Go. Learn what to do when a compliance issue arises.

So, you might be thinking “That great. But, what should a compliance program for my organization look like?

There is a lot of information you can pull from searching, and it can be overwhelming.

Let’s look at how a compliance should operate.

The OIG provides a 2-page outline to help you develop and operate a compliance program. Here are the high-level topics the OIG recommends to “operate an effective compliance program.” For details, review the full outline at the following link.

Operating an Effective Compliance Program

  • Review and Update your Policies and Procedures
  • Measure your Program’s Effectiveness
  • Train. Train. Train.
  • Have open lines of Communication
  • Conduct Internal Audits
  • Enforce Policies and Procedures and Promptly Respond to Compliance Issues

Were you aware that your day-to-day efforts for coding compliance was driven in large part to  OIG’s program to fight fraud and abuse?

Auditing and Coding Compliance

In our new series, we will review the topics of compliance, auditing and coding. To kick off this series, we felt that the remarks made by Principal Deputy Inspector General Joanne Chiedi’s comments at Health Care Compliance Association (HCCA) 2019 Compliance Institute, April 8, 2019, were of value to simply repost.

HHS OIG presented a 2 page pdf covering the highlights of the Deputy Inspector General’s remarks. Here is an outline of the 2 pages for a fast read.

Oversight and Compliance at This Time of Disruptive Innovation in Healthcare

We cannot oversee what we do not understand.

  • Compliance must have a seat and a voice at the innovation table.
  • Give Compliance the data.
  • Compliance and innovation must advance together.

The Healthcare Ecosystem

  • PATIENTS AND FAMILIES are reimagining how and where they want to receive healthcare.
  • CLINICIANS, PROVIDERS, SUPPLIERS, AND PAYERS are rethinking how they deliver smart, quality care to consumers.
  • INNOVATORS AND SCIENTISTS are supporting the delivery of quality healthcare with new digital health technologies, new care delivery models, and new clinical treatments.
  • OVERSIGHT AND COMPLIANCE PROFESSIONALS are working to ensure that the rules of the road are followed, that dollars are well spent, and that patients are protected.

Strategies for Forward-Focused Oversight and Compliance

  1. Agility and Adaptability
  2. Continuous Prioritization
  3. Compliance Leadership
  4. Strategic Partnerships
SpringSoft Medical is in the business of disruptive innovation in healthcare.
Come see what we are doing.

Number and Complexity of Problems Addressed

This week we’ll look at how the various authoritative sites describe Number and Complexity of Problems Addressed.

First let’s look at the AMA’s definition in the now familiar document “cpt-office-prolonged-svs-code-changes.pdf”, titled CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

Page 3: Number and Complexity of Problems Addressed at the Encounter says

… Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction. ….

In a prior posting, we provided an E/M documentation tip from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“

“Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management

  • The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient
  • The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).”

First Coast’s FAQ about Number and complexity of problems addressed at the encounter reiterates the AMA’s definition.

Effective for dates of service on and after January 1, 2021, the “Number of Diagnoses and Management Options” has been changed to “Number and Complexity of Problems Addressed at the Encounter.”

One element in the level of code selection for an office or other outpatient service is the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Novitas’ EM Score Sheet instructions says:

The number and complexity of problem(s) that are addressed during the encounter

This section allows you to identify the office or other outpatient service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.

You can find Novitas’ FAQ on the 2021 E/M at this link.

Some key thoughts from these descriptions are:

Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.

Questions to consider:

Does the documentation identify the conditions addressed?

Does it demonstrate the influence on the patient’s care?


The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

Questions to consider:

Does the documentation describe the risk of morbidity/mortality for the conditions addressed?


Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Questions to consider:

Does the documentation describe the risk of morbidity/mortality of the conditions’ comorbidities?

Counting Labs Done “In House”

We’ve been seeing this question posted searching for authoritative references.

My clinic bills the 81003 for a UA done in house and A1C and prothrombin. My understanding is that it can NOT be counted as a unique test ordered under current guidance but I can’t find where the AMA says this.

Here is what the AMA 2021 CPT(R) Manual says.

Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately.The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately.


Dr. Vinita Magoon, DO, JD, MBA, MPH, CMQ replies to similar questions in his 2021 outpatient office E/M changes FAQ (Nov 6, 2020) n the AAFP’s FPM Journal.

Is use of over-the-counter (OTC) medications automatically considered low risk (as it was under previous guidelines)?

OTC drugs are not necessarily without risk and therefore are not necessarily considered low risk for purposes of MDM. For example, recommending an OTC medication to a patient with several co-morbidities may still result in a detailed discussion of risk. Therefore each instance should be evaluated individually and not automatically characterized as low risk.

If I order a test during one visit and review the same test during the next visit, can I count this as a data point for both visits?

No, you can only get one point for this lab, so the order and review of results is part of the data ordered/reviewed during the first visit. It is not considered a unique data point in a subsequent encounter. When you order a test it is assumed you will review it, therefore both the ordering and the reviewing is attached to the first visit. 

If I review a previous A1c and order a new A1c during the same encounter, does this count as two points under data reviewed?

No. Each unique test will count as one point and a unique test is defined by its CPT code. Since this is the same test with the same CPT code, the reviewing of the previous test and ordering of the new one will together count only as one point.


Novitas Solutions’ addresses this question in their Evaluation and management FAQs

15. Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?

Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.


In an article for AAOS, Margaret M. Maley, BSN, MS of KarenZupko & Associates, Inc. (KZA) writes:

Data are divided into three types:

  1. tests, documents, orders, or independent historian(s) (with each unique test, order, or document counted to meet a threshold number)
  2. independent interpretation of tests
  3. discussion of management or test interpretation with external physician or other QHP or appropriate source

Data include information obtained from multiple sources, interprofessional communications, and interpretation of unique tests. To be considered part of MDM, these data elements cannot be reported separately with a CPT code for reimbursement. [bold font is our emphasis]

For example, if reporting the professional component of a radiologic service, you cannot also count the independent interpretation of the radiograph as a data element in MDM—no double-dipping. A unique test is imaging, laboratory, psychometric, or physiologic data defined by a CPT code. For example, when you order radiographs, three views of the hip and three views of the knee would be considered ordering two unique tests, as each of those radiologic series has its own CPT code.


What other complex scenarios are you running into?