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.
Next year’s CPT manual will include new surgical implants to address knee pain and heart failure, repair diaphragm hernias, and excise pharyngeal neoplasms.
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?
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.
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.
The new ICD-10-CM code for cannabis hyperemesis syndrome improved clinical recognition of the condition, according to a new Centers for Disease Control and Prevention report. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Most veterans receiving Veterans Health Administration outpatient care for major depressive disorder are receiving their recommended treatment, but a growing proportion aren’t, according to a recent study published in JAMA Network Open.
Thyroid disorders challenge outpatient hospital coders because the record often contains symptoms, laboratory values, medications, imaging findings, and surgical history before it contains a clear final diagnosis. Those clues can help a coder understand the encounter, but they do not authorize the coder to diagnose the patient.
CMS intends to introduce multiple new codes next year, according to the proposed 2027 Medicare Physician Fee Schedule. The agency is considering codes for advance care planning services by clinical staff, assessment and treatment of patients who have a reaction to a vaccination, and speech-language services for pediatric patients.
HCPro invites medical coding professionals to take part in the 2026 Coding Salary Survey. This is your chance to see how your salary, credentials, and role stack up against your peers nationwide. The...
Q: What are some red flags associated with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) that might trigger payer audits?
Hospitals are mandated to separately bill HCPCS Level II codes. This longstanding guidance was recently reiterated by two Medicare Administrative Contractors who have published articles on their websites about this specific instruction.
Expiring eviction moratoriums were associated with an increase in outpatient visits for serious mental illness, according to a study published in JAMA Health Forum.
In May 2026, outpatient volumes declined significantly month-over-month and year-over-year in comparison to inpatient admissions, according to a report by Strata Decision Technology. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Beginning January 1, 2027, services for antepartum care, labor management, delivery and postpartum will be coded separately. The old global approach to billing obstetric care was intended to simplify billing, but it no longer reflects the variation and complexity of care across the phases of pregnancy.
Train your coding and clinical teams to think like an auditor before you report modifier -25. Improper payments associated with the modifier have triggered more audits and a variety of attempts to detect and recoup improper payments or stop payments from being issued in the first place.
AI is no longer a distant concept in medical coding and health information management; it is already part of daily work. For many professionals, daily encounters with AI bring a mix of curiosity, caution, and concern.
