Coding & Documentation

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?

Can this doc bill for both health maintenance and a problem-based visit on the same day, if counseling is involved?

Today's practice managers must plan proactively for the new year - finding new ways to cut costs and improve efficiencies.

Coding for observation services can be confounding. Currently, CPT and CMS disagree on which code to report on the second day of observation. In 2011, that is changing.

Can this physician bill for monitoring OB patients in the outpatient setting if he is physically not present?