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.
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.
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.
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.
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...
Expiring eviction moratoriums were associated with an increase in outpatient visits for serious mental illness, according to a study published in JAMA Health Forum.
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?
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.
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.
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.
CMS published the calendar year 2027 Medicare Physician Fee Schedule (MPFS) proposed rule with policies and code changes affecting physician reporting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The redesign of ICD-11 allows for continuous updates, interoperative compatibility with other electronic systems, improved coordination with related terminologies, and a reduced need for post-production clinical modifications. With these changes in mind, Nancy Reading, BS, CPC, CPC-P, CPC-I, explores how this new framework supports significant enhancements to the classification of diagnoses that is built around stem and extension codes and its ability to cluster post-coordinated codes to describe a single condition.
Established in 2000, the inpatient-only list has served as a catalog of procedures that can only be reimbursed by Medicare when performed in the inpatient setting. However, thanks to technological advancements and new surgical techniques, many of these services can now be performed in hospital outpatient departments and ambulatory surgical centers.
Accurately telling the patient’s story requires a thorough review of the entire medical record to identify all conditions that were addressed during the encounter, whether directly or indirectly, by the provider.
Early outpatient follow-up was not associated with differences in hospital-free survival or risk of decline in health-related quality of life among older adults after acute myocardial infarction, according to a retrospective study published in the Journal of Hospital Medicine.
The 2027 OPPS and ambulatory surgical center proposed rule includes a policy that aims to expand CMS’ method of controlling unnecessary increases in the volume of outpatient services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient is in the office today being seen for abdominal pain six days post-op of removal of a benign tumor. After ultrasound, cholecystitis is diagnosed and the patient is scheduled for surgery the next day. Is it appropriate to use modifier -24 in this case?
While you and your team prepare for the new ICD-10-CM codes that will go into effect October 1, make sure you’re also ready for changes to coding instructions for existing codes.
An angiography is a surgical intervention involving the vessels. In angiography procedures, catheters are manipulated into the body to the site of the procedure, dyes are injected, and images are taken.
Rule changes regarding cellular tissue–based products restructured Medicare’s reimbursement strategy for these products. This article covers some related challenges.
Practices and revenue cycle management companies that report obstetric services must be ready to report under the new CPT guidelines for maternity care services by September 1, according to John Horton, MD, FACOG, vice chair of the committee on health economics and coding for the American College of Obstetrics and Gynecology.
Rule changes regarding cellular tissue–based products restructured Medicare’s reimbursement strategy for these products. This article covers some related challenges.
Arthroscopic knee surgery allows orthopedic surgeons to inspect the inside of the joint and make a variety of repairs without having to perform open surgery. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published the fiscal year 2027 ICD-10-CM code set for discharges and patient encounters occurring from October 1, 2026 through September 30, 2027.
Coding professionals are fluent in classification systems such as ICD-10-CM/PCS and CPT, which translate documentation into standardized labels and codes for billing, reporting, and quality programs. Laboratory results, however, travel far beyond the claim. Pamela Banning, MLS (ASCP), PMP (PMI), delves into LOINC and SNOMED CT, two international coding systems applied within laboratory information systems to make lab results computable and consistent across computer systems.
An outpatient care model designed to serve high-cost Medicaid patients was found to significantly reduce healthcare spending, hospital admissions, and emergency department visits, according to a study published in The American Journal of Managed Care.
A coding audit may be conducted by internal staff or external entities, typically representing the insurers paying for the care. When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
An angiography is a surgical intervention involving the vessels. In angiography procedures, catheters are manipulated into the body to the site of the procedure, dyes are injected, and images are taken.
To capture revenue for medically necessary E/M visits and avoid overpayments, your staff must understand when they should and should not use modifiers -24 and -57.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
The Office of the Inspector General announced it is launching a new audit of evaluation and management services billed on the same day as minor procedures.
Cerumen, or more commonly referred to as earwax, is made by the body to protect the ears. Cerumen has both lubricating and antibacterial properties against bacteria, fungi, and water. Code assignment for cerumen removal is based on whether the cerumen is impacted. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The COVID-19 pandemic kickstarted a shift in surgical care from the inpatient to outpatient setting due to elective surgeries in hospitals being suspended. The popularity of outpatient surgeries after the pandemic continued to grow, according to a study published in Medical Care Research and Review.
In a world full of denials, sometimes the best thing you can be is a denials specialist. However, only 11.66% of respondents to the 2025 ACDIS CDI Salary Survey reported that their department included a CDI denials specialist role.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
Medical coding message forums can help coders find the answers to tough coding scenarios and keep claims moving. But remind everyone on your team to make sure their request for help doesn’t create compliance risks or endanger their employment.
Several updates to the Ambulatory Surgical Center payment system recently went into effect, so ensure that your staff knows about these changes, including new HCPCS codes, a deleted code, and revisions.
The Office of the Inspector General announced it is launching a new audit of evaluation and management services billed on the same day as minor procedures effective March 16, 2026.
The AMA announced several changes coming to maternity care service codes for the 2027 CPT code set in a move aimed to allow care to be reported more specifically across all phases of pregnancy. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The human ear is comprised of three parts: the outer, middle, and inner ear. The middle ear is responsible for transmitting sound vibrations to the inner ear. This article will discuss two types of procedures concerning the middle ear: tympanoplasties and tympanostomies.
Practices and revenue cycle management companies that report obstetric services must be ready to report under the new CPT guidelines for maternity care services by September 1.
When is a procedure coded as a biopsy and when is it coded as something else? The right code depends on the purpose of the procedure. The distinction between a biopsy and another procedure is not always clear.
When is a procedure coded as a biopsy and when is it coded as something else? The right code depends on the purpose of the procedure. The distinction between a biopsy and another procedure is not always clear.
Wound care claims are incredibly complex, and they often involve extensive medical histories, multiple diagnoses, and procedures that require detailed documentation to support proper code selection. Even a seemingly minor omission or ambiguity in the documentation could make all of the difference.
ICD-10-CM coding guidelines instruct providers to report a code through the entire fracture healing process—changing only the seventh character to signal the stage of healing. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Early dose adjustments for individuals undergoing methadone treatment in outpatient settings were associated with improved treatment retention, according to a study published in PLOS Medicine.
Train your staff on the first batch of medically unlikely edits for CPT codes that went into effect January 1, 2026, along with new edits that just went into effect on April 1.
The phrase “don’t reinvent the wheel” applies well to the development of an outpatient CDI program when a mature inpatient CDI foundation already exists. The challenge is not whether the wheel can be reused, but how to navigate the differences.
A greater telemedicine uptake among mental health specialists did not result in improved access to care for patients in communities with specialist shortages, according to a study published in JAMA Open Network.
The difference between straightforward and complex cases is now one of the main factors for coding lower endovascular revascularization. Find out how to document and report services with the new code set.
In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The human ear is comprised of three parts: the outer, middle, and inner ear. The middle ear is responsible for transmitting sound vibrations to the inner ear. This article will discuss two types of procedures concerning the middle ear: tympanoplasties and tympanostomies.
Q: What are some tips for properly documenting evaluation and management as it relates to medical decision-making, including improving communication with providers?
Radiation oncology is a specialty utilizing radioelements either externally or internally to treat medical conditions such as cancer. This article serves as a primer for coding radiation oncology services.
The phrase “don’t reinvent the wheel” applies well to the development of an outpatient CDI program when a mature inpatient CDI foundation already exists. The challenge is not whether the wheel can be reused, but how to navigate the differences.
Net spending on Medicaid outpatient prescription drugs grew substantially in recent years while the number of prescriptions paid by Medicaid only grew slightly, according to a recent issue brief from KFF.
Modifier -59 is used to describe a distinct procedural service. It’s appended to codes to identify procedures/services that are not usually payable when reported together. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS is signaling a clear shift in how it views risk adjustment, quality performance, and documentation integrity. For coding and CDI professionals, this moment represents not a threat, but a critical inflection point.
Q: A patient presents with acute respiratory failure with hypoxia due to an accidental heroin overdose. What is going to be sequenced first: the acute respiratory failure or the poisoning?
Modifiers -50, -RT, and -LT are laterality modifiers that clarify a CPT code by defining which side of the body the service was performed on. But knowing when to use them is not always immediately clear. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Changes to the Medicare provider-based billing requirements for off-campus outpatient departments are coming with the passage of the Consolidated Appropriations Act last month.
Radiation oncology is a specialty utilizing radioelements either externally or internally to treat medical conditions such as cancer. This article serves as a primer for coding radiation oncology services.
The CPT manual includes many types of biopsies: fine needle aspiration (FNA), core needle, and skin (tangential, punch, and incisional). This article focuses mainly on FNA biopsies and its complicated guidelines, while also touching on core needle biopsies.
When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration, as each facet impacts the level of staffing required to conduct the reviews. Coding auditors should pick a few key elements to review, and the items should be of importance to your organization. Ideally, the topics will focus on issues that are frequent or require reassurance. Note : To access this free article, make sure you first register if you do not have a paid subscription.
For CPT and ICD-10-CM coding of fracture treatment, coders—particularly those in orthopedic practices—need to identify several vital pieces of information from the physician’s note. This article covers the keys pieces of information and other tips to ensure accurate coding of fracture treatment.
The February 4 issue of CMS’ MLN Matters outlines the January 2026 update to the hospital OPPS, including COVID-19 CPT code changes; new HCPCS codes for drugs, biologicals, and radiopharmaceuticals; and new unlisted skin substitute product HCPCS codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Practitioners work hard, especially when they perform critical care services. Training clinical and coding staff with real-world examples can make sure providers get full credit for their work. Share this case with staff and ask them to decide what services can be reported.
A number of Medicare telehealth flexibilities extensions in place until January 30, 2026, lapsed during the partial U.S. government shutdown that began January 31, 2026.
The 2026 Outpatient Prospective Payment System final rule isn’t for the faint of heart. CMS finalized many of the major changes from the proposed rule, although the agency did pull back on certain key areas. With big shifts in compliance and reimbursement taking effect, coders have their work cut out for them.
The CPT manual includes many types of biopsies: fine needle aspiration (FNA), core needle, and skin (tangential, punch, and incisional). This article focuses mainly on FNA biopsies and its complicated guidelines, while also touching on core needle biopsies.
Emergency department visits resulting in outpatient treatment increased sharply, while visits leading to inpatient admission did not—particularly among Medicaid patients—according to research recently published in JAMA Health Forum.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
Medical coders work with many different code sets including CPT, HCPCS, ICD-10-PCS, and ICD-10-CM. This means coders need to be well-versed in medical terminology. One terminology not often talked about in coding circles is the Systematized Nomenclature of Medicine Clinical Terms—despite the system being around for more than 20 years.
Take three steps when an assistant surgeon helps during a procedure. First, make sure an assistant-at-surgery modifier is appropriate for the procedure. Second, make sure the primary surgeon’s note explains why they needed the help of a qualified healthcare professional (QHP) or another physician for the procedure. Third, make sure you select the correct modifier, based on the assistant’s credentials and role.
Our experts answer questions about the multiple sclerosis medication administration, coding a crack cocaine overdose, and Medicare administrative contractors.
A study recently published in JAMA Network Open examined trends in outpatient mental health care among Medicare fee-for-service beneficiaries before, during, and after the COVID-19 pandemic.
Part B providers are facing a radically different reimbursement landscape in 2026. In the 2026 Medicare Physician Fee Schedule final rule, CMS moved ahead with many of the changes it floated in the proposed rule, including fundamental changes to how the conversion factor is calculated, relative value unit valuation, payments for skin substitutes, and more.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
CMS released the fiscal year 2026 ICD-10-CM files for use for discharges and patient encounters occurring from April 1 through September 30, 2026. Take time to review the updates. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medical coders work with many different code sets including CPT, HCPCS, ICD-10-PCS, and ICD-10-CM. This means coders need to be well-versed in medical terminology. One terminology not often talked about in coding circles is the Systematized Nomenclature of Medicine Clinical Terms—despite the system being around for more than 20 years.
