When coding level-based evaluation and management services based on medical decision-making, the amount and/or complexity of data to be reviewed and analyzed is one element that may be used to reach a code. This article covers what that entails. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
A study recently published in JAMA Network Open examined the effects of outpatient rehabilitation programs for patients with post-COVID-19 condition. Find out how the patients benefited from these programs.
The 2025 CPT code set includes new codes for synchronous audio-only and audio-video visits. These visits take place between a patient and a physician or other qualified healthcare professional. This article covers what you need to know about these new codes.
Telehealth rules and requirements from before the COVID-19 public health emergency were restored on January 1, 2025, but CMS will hang on to a few waivers. This article outlines several telehealth waiver extensions, as well as recent changes to telehealth law.
Prolonged service codes give practices the opportunity to earn additional revenue when the treating clinician spends extra time on a patient’s care. Evaluation and management (E/M) office visit codes include prolonged service code for exclusive use with office E/M services. Learn some quick facts about prolonged service codes and E/M visits.
Physicians and other qualified healthcare professionals have the flexibility to select an evaluation and management level based on either the complexity of medical decision-making or the total time spent on the date of the encounter. This article covers documenting E/M services based on time.
Patients diagnosed with a malignant neoplasm, commonly known as cancer, are now living longer due to better treatments. In 2025, there are 47 new ICD-10-CM codes to be used to report lymphoma in remission. This article broadly reviews those new codes.
Physicians and other qualified healthcare professionals have the flexibility to select an evaluation and management level based on either the complexity of medical decision-making or the total time spent on the date of the encounter. This article covers documenting E/M services based on time. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Level-based evaluation and management services may be coded based on medical decision-making (MDM). To reach a code based on MDM, the documentation must support at least two out of the three elements. This article covers the first element: number and complexity of problems addressed at the encounter.
The major revisions to the coding guidelines for office/other outpatient evaluation and management visits are almost four years old. And yet, practices continue to face challenges when they document and report these services. This article outlines four actions to avoid and four challenges that practices face when they report these high-value, high-volume services.
Black Book Research recently surveyed more than 4,000 health information management professionals about their concerns for the new year. Find out what issues are at the top of their minds for 2025.
Q: What were the AMA’s goals for revising evaluation and management (E/M) services that were implemented starting in January 2021 and continued in January 2023?
Enhanced care management codes for advanced primary care management services in the physician fee schedule proposed rule have been cleared. This article discusses the terms billing providers and their teams must meet when providing these services.
Coders should use particular care when selecting diagnosis codes, always selecting the most specific code possible, based on the clinician’s documentation. This article covers diagnosis coding guidelines to help avoid using vague or non-specific diagnosis codes that will likely result in denials. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Patients diagnosed with a malignant neoplasm, commonly known as cancer, are now living longer due to better treatments. In 2025, there are 47 new ICD-10-CM codes to be used to report lymphoma in remission. This article broadly reviews those new codes.
CMS recently issued a proposed rule for 2026 that includes provisions aimed at limiting Medicare Advantage in-network cost-sharing for behavioral health services to be no greater than the traditional Medicare rates. Find out what the proposed behavioral health cost-sharing standards are in the proposed rule.
CMS finalized its proposal to relax restrictions on complexity of care add-on HCPCS code G2211. The changes come in response to stakeholder concerns that the current CMS policy is disruptive to the way providers normally treat patients. This article covers how to prepare for this update.
A recent OIG audit estimates that Medicare improperly paid $190.1 million for outpatient services provided to hospice enrollees over five years. Learn how the audit was performed and why the payments were improperly made.
Assigning proper codes plays a role in the integrity of medical records, supports effective communication between healthcare providers, and safeguards a practice against compliance issues. This article discusses some common dermatological conditions and their respective ICD-10-CM codes/categories.
The changes proposed in the final rule for Medicare’s burgeoning behavioral health category have been finalized, expanding its purview beyond previous therapeutic models and even into digital care engaged by the patients themselves. Review those changes in this article.
Q: Why is modifier -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service) scrutinized?
Selecting a level of evaluation and management (E/M) service can be based on either the complexity of medical decision-making or the total time spent on the date of the encounter. Providers need to decide which to use. This article covers the pros and cons of both methods.
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. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
Take in the details of the 16 new telemedicine codes for real-time encounters in the CPT 2025 manual while you wait to see whether private payers adopt the services or CMS sways from proposed non-coverage of the 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.
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.
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.
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.
CMS recently announced updates to the January 2025 Integrated Outpatient Code Editor, including new HCPCS codes and changes to a handful of status indicators.
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.
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.
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.
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)?
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.
Take in the details of the 16 new telemedicine codes for real-time encounters in the CPT 2025 manual while you wait to see whether private payers adopt the services or CMS sways from proposed non-coverage of the codes.
Our experts answer questions about serotonin syndrome, the difference between National Correct Coding Initiative edits and medically unlikely edits, and prolonged service codes.
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?
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.
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.
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.
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.
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.
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?
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.
Work with pharmacists to make sure patients who receive antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection prevention don’t miss a treatment when CMS implements the national coverage determination (NCD) for a new preventive service that includes pre-exposure prophylaxis (PrEP) for HIV.
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.
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.
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.
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?
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.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
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?
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.
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.
Gain unique and fresh insights from clinical documentation integrity professionals in unique settings to help you strengthen your organization’s denials management efforts.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
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.
Protect your office/outpatient E/M claims from front-end denials and post-payment recoupments with the freshest information from Medicare administrative contractors (MAC).
HIPAA has protocols for when patients’ protected health information can be used for research and marketing. This means you must understand privacy rule limitations and your organization’s policies and procedures before releasing any PHI in these situations. 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?
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?
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.
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.
The best technical security in the world cannot prevent breaches of protected health information if people are careless. Coders, billers, and HIM professionals should then learn to protect confidential health information by following proper security procedures and creating effective passwords.
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?
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.
Our experts answer questions about reporting total knee arthroplasty in CPT, medically unlikely edits adjudication indicators, and coding for anticoagulation management visits.
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.
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.
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.
