Coding & Documentation

Level 5 codes based on "breadth of management" need to clearly explain "why" the reported illnesses pose significant risk to patients. Should the physician add a statement to to her assessment that explains why the combination of multiple chronic illnesses pose a risk to the patient's morbidity/mortality?

A discussion arose between the auditors in my office regarding "double dipping" and I am wondering if you would mind clarifying something for us. One auditor says that it is permissible to obtain a review of systems (ROS) from the CC of "arm pain" - using arm as the location in the HPI and pain as the ROS under MS. I have never audited in this manner and would appreciate any advice or direction you can offer.

This doc wonders if he can mix and match body areas and organ systems for an expanded problem-focused exam.

When counting points for the data reviewed in E&M, do you count "independent review of image, tracing, or specimen" (two points), for example, when a cardiologist sees a patient, interprets an EKG, and provides an E&M service?

I know that there are going to be significantly more codes with ICD-10, but will the rules change regarding how codes are assigned?

I keep hearing about the new modifier 33 but it's not in the CPT manual. Am I supposed to be using it?

Repeating documentation for the HPI and ROS, is it allowed?

Have the rules changed for CERT (Comprehensive Error Rate Testing) reviews?

Did the definition of healthcare fraud change?

How can I avoid an audit finding of "insufficient documentation" for medical decision making?

Can Medicare require documentation that includes the full physician's note for 99204s and 99205s?

Is there a new modifier for CPT in 2011?

My providers seem really confused about using consult codes for Medicare patients in the hospital. Is the use of admission codes confined to the day the patient is admitted?

Can this OB/GYN code a 99211 for fetal stress testing?

It seems the traditional understanding of modifier 59 has changed. Here's information for your medical practice.

Looking for the proper way to use modifier -25 at your medical practice? Here is some expert medical coding advice.

Coding questions? We've got the answers

Coding questions? We've got the answers

Changes with ICD-9 and CPT codes have been commonplace for several years and will almost assuredly continue, even with the adoption of ICD-10 in 2013. We must adapt to the change by updating our practice management systems to include the changes to ICD-9, CPT, and new rules by CMS and insurance payers.

Coding questions? We've got the answers.

Here's some medical coding guidance on CERT reviews; a new CPT modifier; Medicare visit reviews; and more.

The Affordable Care Act added a new Medicare Annual Wellness Visit. Contrary to patient and physician expectations, it is not a physical exam.

This physician wants to know if he can bill for infusion services in an outpatient setting.

How to code for dental pre-op exams?

This doc wants to know how to bill inpatient services using the primary-care exception rule.

Why spend hours on the phone with payers when you can check online in minutes?

Clinicians should make sure they clearly document the patient's level of risk when comorbid conditions are present.

This physician wonders how to get around documenting the "I saw and examined" clause in every patient record.

Does prescribing a new medication qualify as a moderate level decision making?