Coding & Documentation

Your guide to coding and documentation best practices.

Completing all necessary documentation to describe the individual’s current condition, treatment needs, interventions, and medications must be done with precision.

Manual coding is slow, inaccurate, and cost inflexible.

Any billing changes won't come for a while.

What you need to know about prolonged services, medical assistant, and E/M codes.

What are the key differences between manual and autonomous medical coding processes?

Do EMRs result in higher coding for Evaluation and Management codes? Let’s take a look back to see.

Dodge these common problems with medical coding.

When employees are unsupported, overwhelmed, and struggling to stay up-to-date on the latest rules, mistakes are bound to happen.

What you need to know to avoid claim denials and to maximize practice revenue.

Get prepared for next year's changes.

During a typical office visit, physicians may provide evaluation and management (E/M) services, minor procedures and more. The question is: Can they bill for each one separately?

For primary care practices, earning enough revenue to meet overhead expenses and provide quality care has always been a challenge. But practices often make the challenge even greater through sloppy coding and billing, leading to delayed or incorrect reimbursements from payers.

What you need to know about coding a follow-up appointment for Type 2 diabetes.

Don't lose out on revenue by misidentifying patients.

Prior authorizations continue to top the list of annoyances for physicians.

An internal medical coding and billing audit can ensure a practice is billing correctly.

Proper documentation and taking advantage of new coding designations can ensure practices are getting the most for the care they provide.

CMS says that the modifier is being overused and misused.

Make sure you don't fall into these coding pitfalls.

Some telehealth provisions introduced to combat the COVID-19 pandemic have been continued until at least the end of 2023.

What the new physician fee schedule may mean for your practice.

While helpful, the increase in electronic patient information creates more opportunity for errors, omissions, or mistakes that can ultimately lead to an unintended patient outcome and subsequent evidence against a provider in a legal proceeding.

Things owners and administrators should know when preparing for interoperability in their practice.

The risk of malpractice and negligence is hurting the medical billing industry. Here’s a brief article talking about various risks involved with these threats to practices, clinics, and coders.