01.

List of all providers including:

 Name

 Credential (MD, DO, etc.)

 Provider NPI

NOTE: Please do not provide information for providers not involved in the acquisition.

 Yes  N/A

02.

Does practice use a management company or billing company? If yes, provide name of company and copy of contract(s).

 Yes  N/A

03.

CPT/Modifier utilization for each provider involved in the acquisition. Specifically, the list should indicate:

 Provider

 CPT

 Modifier(s), if applicable

 Number of times each code was billed during the report period

(See Example Below)

This information must be in Excel. All submitted codes must be attributed to a specific provider, not grouped under rooms (ex. Lab or Injection Room)

 Yes  N/A

04.

Any policies/procedures that are related to coding and billing.

 Yes  N/A

05.

List and describe discounts or special offers to patients.

 Yes  N/A

06.

Does your practice use electronic medical record, billing or scheduling systems? If yes, describe the system(s) and provide any related documentation, licenses, or agreements.

 Yes  N/A

07.

Documentation template used by the practice?

 Yes  N/A

08.

Current encounter form/charge document used by the practice?

 Yes  N/A

09.

Any documentation related to current compliance program?

 Yes  N/A

10.

Summary of RAC or other audit correspondence (Medicare or Medicaid)

 Yes  N/A

11.

Any internal/external consultant or audit reports related to coding, billing, documentation?

 Yes  N/A

12.

Are allied health professionals (NP, PA) billed to Medicare/Medicaid directly; or Incident to a physician?

 Yes  N/A