Prior to the 1970s, there was not an objective method of evaluation and management documentation, which led to physicians making unscientific decisions about patient treatment. Now, one of the general ways that providers document their services is the SOAP format, which helps them organize their thoughts for a patient encounter. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The fiscal year 2027 update to the ICD-10-CM code set includes new, deleted, and revised codes, as well as hundreds of changes to “Excludes” notes and “Code Also” indications. This code set was produced to show greater coding specificity by publishing codes with greater clinical specificity.
Next year’s CPT manual will include new surgical implants to address knee pain and heart failure, repair diaphragm hernias, and excise pharyngeal neoplasms.
Less than one-half of adults discharged from emergency departments for diabetes-related encounters obtain outpatient follow-up care within 30 days, according to a recent study published in the Journal of General Internal Medicine.
Q: When coding endoscopic procedures, some CPT codes have multiple procedures bundled in a single code. How do coders report when one of the procedures isn’t done?
