The concept of social determinants of health (SDOH) has transformed significantly, advancing from increased awareness to data integration and the development of tools and frameworks. This article explores the importance of integrating SDOH into the healthcare framework and the coding process, as well as best practices for leveraging this data to inform health interventions.
CMS implemented modifier -FS (Split [or shared] E/M visit) as part of a major revision to its rules for split/shared services on January 1, 2022. This article provides tips for using modifier -FS from top reporters as it approaches its third year of active status.
With CMS publishing annual updated versions of its Medicare National Correct Coding Initiative (NCCI) Policy Manual, as well as quarterly updates to the individual NCCI edit files, it is often hard for facilities to keep up with the changes. This article details the latest updates, as well as provides insights on implementing NCCI-associated modifiers and tips for preventing and overriding common edits.
CMS may have major changes in store for outpatient hospital reimbursement and compliance, according to the 2025 Outpatient Prospective Payment System proposed rule. The proposed rule, released in July, includes potential changes to payment, coding, and billing for hospital outpatient services.
Medicare patients who qualify for the new preventive service designed to protect them from HIV will be eligible for up to eight counselling and screening services a year, according to a recently released CMS national coverage determination.
CMS recently announced updates to the January 2025 Integrated Outpatient Code Editor, including new HCPCS codes and changes to a handful of status indicators.
Protect your practice by understanding the code level selection risks that could impact E/M office visit claims. Incorporate the guidance in this article into your compliance plan to make sure they stay on your risk radar. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What codes should a coder consider for a patient diagnosed with an eating disorder (e.g., anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder)?
ICD-10-CM contains specific pain codes based on the type of prosthetic device, mesh, or implant. This article reviews best practices for using placeholders and selecting the correct encounter code, as well as other considerations when using diagnosis codes.
In January 2024, CMS released guidance for the implementation of the office and outpatient evaluation and management visit complexity HCPCS add-on code G2211. Courtney Crozier provides a breakdown of the code, including documentation requirements and appropriate and inappropriate billing scenarios.
Looking to improve the speed and accuracy of your trigger point injection coding? This article will help you spot the information you need to code the services and find areas where your treating providers need extra help to improve their documentation.
How do you code the conversion of a previous unicompartment knee arthroplasty to a total knee arthroplasty when there is no conversion code? This article reviews the AMA’s and the American Academy of Orthopaedic Surgeons’ takes on this issue. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Revisions to the E/M guidelines have simplified documentation and eliminated unnecessary documentation. Clinicians may choose levels of E/M services based on time or level of medical decision-making. Nancy M. Enos, FACMPE, CPC-I, CPMA, CEMC, CPC emeritus , dives deep into both processes and provides best practices for each.
Q: Based on the instructions for sacroiliac joint injections, our physicians believe they can bill the injection and report imaging separately if they use ultrasound. Is this true?
The American Medical Association recently announced new codes, deletions, and revisions included in the 2025 CPT code set. Explore these notable updates to the code set.
The American Medical Association recently announced new codes, deletions, and revisions included in the CPT 2025 code set. Explore these notable updates to the code set.
Q: How do I know when to use CPT code 26370 vs. 26356, for a finger tendon repair? Is it based on whether there is an intact flexor digitorum superficialis (FDS) tendon, or whether the cut or laceration of the flexor digitorum profundus (FDP) tendon was in Zone II?
According to a recent analysis, healthcare organizations are submitting more prior authorization requests to Medicare Advantage plans and more of those requests are being denied. Review the analysis’ findings to be more aware of prior authorization processes and CMS’ efforts to streamline them.
When an office/outpatient visit is coded based on time, think beyond face-to-face time to get full credit. This article reviews time-based coding, how to count time, which activities count toward time, and which ones don’t. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The connection between medical necessity and diagnosis coding should be included with your training on the 2025 update to the ICD-10-CM code set. This article serves as a refresher on medical necessity, possible ICD-10-CM conflicts, and other best practices.
Critical access hospitals ensure that people living in remote, rural, or underserved communities still have access to medical care. Learn about the ins and outs of their reimbursement models and other billing and coding considerations.
A recent draft local coverage determination includes detailed coverage requirements for chronic migraine treatment. This article reviews the terminology that drives migraine coding.
Patients who self-reported housing instability often didn’t have the correct ICD-10-CM codes documented in their record, according to a recent study. Review the results of the study and be more aware of the importance of properly documenting housing insecurity to ensure appropriate housing and medical services are delivered.
The ICD-10-CM changes for fiscal year 2025 are coming October 1, 2024. Learn about some of the changes to guidelines, notes, wording in current categories, and expansion of code categories.
Q: What ICD-10-CM code should we report for a periprosthetic fracture due to an injury? Do you use the S codes for a traumatic fracture with a secondary code for replacement, or do you select a code from the M97 (Periprosthetic fracture around internal prosthetic joint) category?
Being able to differentiate between the types of colonoscopy procedures in outpatient settings is essential to ensure that the correct codes are documented. This article reviews the main types of colonoscopies and the factors that determine how they are coded. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
With CMS’ release of its proposed 2025 Medicare physician fee schedule, the agency proposed many policy changes and revisions. Explore several of them and other announcements made by CMS.
Gain unique and fresh insights from clinical documentation integrity professionals in unique settings to help you strengthen your organization’s denials management efforts.
Stand-alone and integrated physician practices have unique challenges and requirements regarding revenue cycle management. Discover how revenue integrity programs in professional fee settings are designed and function.
Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?
CMS’ proposed rule to revise the Medicare hospital Outpatient Prospective Payment System for calendar year 2025 has been released. Review some of the proposals that could directly impact your organization.
Q: Is it appropriate to code metabolic encephalopathy related to alcohol withdrawal or alcohol withdrawal delirium? And if so, how do you successfully defend against denials?
The concept of expanding clinical documentation integrity (CDI) programs into the outpatient setting is not new but the COVID-19 pandemic threw a wrench into a lot of organizations’ expansion plans. Now it might be time for organizations to revisit the idea. Review the steps to expand into outpatient CDI.
It can be especially challenging to thoroughly document rendered services in the emergency department due to the unique needs of the setting. Hamilton Lempert, MD, CEDC, reviews several areas of critical care coding that may trip up clinicians and coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS finalized many behavioral health requirements related to social determinants of health risk assessments, care management services, and more with the 2024 Medicare Physician Fee Schedule final rule. With all these changes where do providers start?
It is important for both coders and providers to understand that they can report critical care along with other services such as ED E/M and CPR. Hamilton Lempert, MD, FACEP, CEDC, answers questions about the proper ways to do so, as well as the importance of doing so. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
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.
Q: A specialty society's fact sheet offers guidance for determining E/M level when an ICD-10-CM social determinant of health code affected the diagnosis or treatment. What is Medicare's policy on this?
CMS recently finalized a multitude of new price transparency requirements in the 2024 Outpatient Prospective Payment System (OPPS) final rule. These requirements have staggered enforcement deadlines, which means that revenue integrity professionals have their work cut out for them in the coming year to ensure their organization is in compliance.
A few years ago, providers started using new guidelines for their office/outpatient services that based the level of service on medical decision-making (MDM) or time on the date of the face-to-face encounter. This article focuses on office/other outpatient coding basic guidelines that apply to all level-based E/M codes. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently released an updated MLN fact sheet reminding providers about documentation requirements for requests from its Comprehensive Error Rate Testing (CERT) program.
CMS recently released a revision to its benefit policy manual to stress that codes and modifier combinations should be reported when social determinants of health risk assessments and Medicare annual wellness visits are conducted together.
Q: Should signs, symptoms, or unspecified ICD-10-CM codes (e.g. M54.50 [low back pain, unspecified]) be reported when the condition (e.g. M51.36 [other intervertebral disc degeneration, lumbar region]) is also reported on the same outpatient encounter?
CMS updated its July 2024 HCPCS Quarterly update file in May with a total of 70 new HCPCS codes, 11 discontinued codes, and 32 revised codes. All code changes will be implemented July 1.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , delves into ICD-10-CM and CPT coding for urogynecology, a subspeciality that provides necessary crossover care for female patients. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Nancy Reading, RN, CPC, CPC-P , explains how understanding liver disease and its many complications is key to supporting higher-specificity ICD-10-CM coding and reimbursement.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , and Mercedes K. C. Dullum, MD, FACS, FACC , describe the advantages of creating CDI programs in outpatient settings and how they can decrease gaps in patient care and improve financial management.
Hamilton Lempert, MD, FACEP, CEDC, reviews the basics of critical care services in CPT and addresses common reporting questions, such as services that pass midnight, continuous care, and which clinical tasks count toward critical care. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The Food and Drug Administration’s (FDA) emergency use authorization for Pemgarda, a pre-exposure COVID-19 prophylaxis, has led to the release of HCPCS Level II codes for the drug and its administration.
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.
Julia Kyles, CPC , examines the factors of medical necessity required to decrease chance of denials for preoperative E/M visits, including who performs the visit, associated risks, and the patient’s health.
CMS published a summary of its first quarter 2024 HCPCS Level II code update application decisions. There were 48 additions, two code definition revisions, and seven discontinuations.
Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Lynn Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC , covers FAQs she has received, specifically about CPT reporting for arthrodesis, acromioplasty, arthroplasty, arthroscopy, and spinal decompression procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS proposed hundreds of ICD-10-CM code changes in the 2025 IPPS proposed rule, published April 10, including 252 new codes, 13 revised codes, 36 invalidated codes.
Ronald Hirsch, MD, FACP, CHCQM, CHRI , and Valerie A. Rinkle, MPA, CHRI , explore common causes of denial, including prior authorization, missing documentation, medical necessity, and EHR formatting.
Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC , answers frequent questions she receives from providers pertaining to physician coding for CPT orthopedic services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Tonya Chandler, RHIT , brings light to the declining mental health in youth, clarifies possible contributing factors, and explains how to report mental and behavioral conditions in ICD-10-CM with several case scenarios.
Physician coders should watch out for recently implemented edits to codes that debuted January 1 in the quarterly updates to the NCCI files. The latest updates introduce 2,171 new PTP edits and 164 new MUEs.
CMS published its HCPCS Quarterly Update in March, which heralded the sum of 94 HCPCS Level II code additions, discontinuations, and definition revisions. The changes became effective April 1.
The lack of interaction with remote work has a variety of impacts. Managers must develop strategies for remote onboarding and training, find different ways to measure productivity, and keep employees engaged.
Orthopedists perform injections and aspirations to address a range of ailments, but reporting injections can be difficult. This article reviews proper CPT coding for sacroiliac joint injections and joint arthrocentesis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Katie Patterson, CPC , summarizes the Medicare Quality Payment Program, provider qualifications, clinician participation, and how they work to achieve the program’s main objectives.
Shelley C. Safian, PhD, RHIA, CCS-P , and Mary A. Johnson, MBA-HM-HI, CPC , review the purpose of modifiers and analyze their integral part in reporting encounters, receiving reimbursement, and promoting continuity of care. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , analyzes the challenges that both inpatient and outpatient CDI specialists encounter and offers advice to lessen provider opposition to participating in outpatient CDI.
Julia Kyles, CPC , summarizes the advice CMS provided during a January event about reporting HCPCS add-on code G2211 for increased complexity with E/M codes.
C. diff results from a disruption of the normal bacterial flora of the colon. Recognize the diagnostic criteria, treatment, and ICD-10-CM coding tips for reporting this disorder. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS retroactively added two new CPT codes for respiratory syncytial virus (RSV) vaccine administration. The codes affect services rendered on or after October 6, 2023.
Artificial intelligence (AI) has burst on the scene with numerous clinical and coding applications for providers. This article looks at how the technology can be used and where human oversight is still required.
Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, and Karla VonEschen, MS, CPC, CPMA, CCDS-O, take a look back at the progression of diagnosis and mortality coding before looking ahead to ICD-11 and how coding departments can prepare for it.
Heart failure affects more than 6 million adults in the U.S. and costs the nation more than $30 billion. Review ICD-10-CM guidance and documentation details required for accurately reporting the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Teresa Seville, RHIT, CCS , explains that a thorough review of code updates must include analysis of the addenda, including index, tabular notes, guidelines, and committee meeting highlights.
Most fracture cases originate in the ED, so orthopedic coders must understand the various scenarios that may arise based on the patient’s condition and the intent of the performing clinician. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS published a summary of its fourth quarter 2023 HCPCS Level II code update application decisions, including 36 additions, four revisions, and 18 deletions.
The behavioral health coverage that CMS calls among the most important in Medicare history were finalized and expanded in the 2024 Medicare Physician Fee Schedule final rule.
Diane Pittman, CPC, CPMA, CRC, CCD-O, and April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O , explain how reporting ICD-10-CM social determinants of health, their context, and coder feedback can influence natural language understanding.
For accurate CPT and ICD-10-CM coding of fractures, coders will need to identify many pieces of information, including location and type. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS posted its 2024 Therapy Code List and Dispositions on December 28. This list indicates whether therapy services, as distinguished by HCPCS Level II and CPT codes, are recognized under CMS as “sometimes therapy” or “always therapy.”
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Julia Kyles, CPC , reviews the 2024 First Quarter National Correct Coding Initiative (NCCI) code update, which included 929 new procedure-to-procedure edit pairs.
This Q&A with Nancy Enos, FACMPE, CPC-I, CPMA, CEMC , covers independent historians, independent interpretations, discussion with external physicians, risk, and billing for separate E/M visits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
