Medical decision-making (MDM) documentation has gained increased importance in recent years to justify a visit’s medical necessity. Review CMS’ MDM table and guidelines to take the guesswork out of your coding.
Our experts answer questions about reporting total knee arthroplasty in CPT, medically unlikely edits adjudication indicators, and coding for anticoagulation management visits.
Make sure staff who handle audit requests understand when a missing signature should—or should not—trigger an automatic denial of your claims or prior authorization requests. Recent guidance from CMS clarifies how auditors should proceed when a medical record lacks a signature.
Hamilton Lempert, MD, FACEP, CEDC, reviews the basics of CPT critical care services and addresses common reporting questions, such as services that pass midnight, continuous care, and which clinical tasks count toward critical care.
Tonya Chandler, RHIT, writes about mental health status in youth, clarifies possible contributing factors, and explains how to report mental and behavioral conditions in ICD-10-CM with several case scenarios.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, explains how to report neonatal respiratory failure, including meconium aspiration, failure to thrive, and associated symptoms in ICD-10-CM.
This article reviews malware basics and covers tips that healthcare employees can implement to avoid cyberattacks that could put protected health information (PHI) at risk.
Our experts answer questions about ICD-10-CM coding for diabetic patients with hyperglycemia, CPT documentation requirements for wound sizing, and more.
