Artificial intelligence has revolutionized healthcare operations, offering speed and efficiency in certain tasks, but in a field where precision drives reimbursement and compliance, speed without accuracy can turn efficiency into liability. Karen R. Lane, MSN.ed, CCDS, CCDS-O, CDIP, RN, delves deep into one critical risk of using AI: hallucinations in the context of appeals.
Transcatheter aortic valve replacement is a minimally invasive procedure developed to treat patients with severe aortic stenosis who are considered high-risk or unsuitable candidates for traditional open-heart surgery. Learn from Jane Arbogast-Schappell, CCS, CPC, CCC, CIRCC, as she walks through the procedural coding for both inpatient and outpatient settings.
You’ll have to wait a while longer for National Correct Coding Initiative edits for 2026-effective codes. However, the latest quarterly NCCI update will include new medically unlikely edits for a variety of HCPCS codes that went into effect in July and October 2025.
MDaudit, a revenue integrity software platform, recently released its annual report that examines trends in coding denials, audits, and technology based on data from the first three quarters of 2025. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Providers will have more opportunities to report +G2211, the complexity of care HCPCS add-on code. Effective January 1, 2026, providers will be able to report the code with evaluation and management encounters in more settings, CMS announced in the final 2026 Medicare Physician Fee Schedule.
In the ever-evolving world of healthcare coding, staying grounded in the fundamentals is not just best practice, it’s a necessity. As regulations shift, payer expectations tighten, and productivity pressures mount, coding professionals must continually revisit the core principles that ensure accuracy, compliance, and integrity in clinical documentation and billing.
CMS finalized changes to the Medicare Diabetes Prevention Program in the 2026 Medicare Physician Fee Schedule final rule, including updating weight collection requirements, extending flexibilities allowed during the COVID-19 public health emergency, and updating the online delivery modality of the program.
Coders will find a fresh batch of CPT codes that they can begin reporting on January 1, 2026, with 288 new codes coming online. The code update, announced with the release of the 2026 CPT Manual, also includes 46 revised code descriptors and 84 deleted codes.
On October 31, 2025, CMS released the 2026 Medicare Physician Fee Schedule (MPFS) final rule, which includes implementing two separate conversion factors, updating telehealth services, and changing the payment policy for skin substitutes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Beginning January 1, 2026, the AMA will add a number of changes to CPT codes for two related sections: Digitally Stored Data Services/Remote Physiologic Monitoring; and Remote Physiologic Monitoring Treatment Management Services.
A systematic review and meta-analysis published by JAMA Network Open suggests that outpatient follow-up within 30 days of discharge can be associated with reduced risk of readmission, but that association may vary due to risk factors, such as the patient’s age and disease.
Chronic conditions are among the most frequently encountered diagnoses in the outpatient setting. Accurate coding of these conditions is critical not only for proper reimbursement but also for compliance, quality reporting, and patient care continuity.
Our experts answer questions about poisonings vs. adverse effects , coding neoplasm-related conditions, and office and outpatient E/M visit complexity.
The ICD-10-CM update for 2026 included 213 new codes that incorporated the “flank” as an anatomic area related to injuries. Genetic diseases also continue to make big inroads into the tabular list of diagnoses.
While CMS declined to consider any codes for revaluation under the agency’s potentially misvalued codes policy for calendar year (CY) 2026, the agency proved responsive to nominators’ requests for certain codes to be valued or revalued.
Q: In the 2026 ICD-10-CM update, in the neoplasm chapter there are some added specific codes for inflammatory neoplasm of the breast. How do those differ from other types of breast cancer?
It’s been two weeks since the federal government shutdown began, as well as when Medicare telehealth waivers and flexibilities were set to expire. In a special edition of the MLN Connects newsletter released just as the shutdown began on October 1, 2025, CMS provided some guidance to providers. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The ICD-10-CM update for 2026 included 213 new codes that incorporated the “flank” as an anatomic area related to injuries. Genetic diseases also continue to make big inroads into the tabular list of diagnoses.
The 2026 Medicare Physician Fee Schedule proposed rule includes significant potential changes to telehealth billing and coverage, conversion factor calculations, relative value unit weights based on site, skin substitutes, behavioral health, and more.
A review of 800 studies found that electrocardiogram interpretation assisted by artificial intelligence has the potential to improve diagnostic accuracy and enable earlier detection of cardiac conditions, particularly in resource-limited outpatient settings.
Join us on the podium at the 2026 Revenue Integrity Symposium (RIS), to be held September 24-25, 2026, in Savannah, Georgia. We’re now accepting proposals to speak at 2026 RIS. The deadline to apply...
CMS recently updated its MLN Booklet for evaluation and management services with changes to the sections regarding office or outpatient E/M visits, critical care services, hospital outpatient clinic visits, and telehealth services.
Chronic conditions are among the most frequently encountered diagnoses in the outpatient setting. Accurate coding of these conditions is critical not only for proper reimbursement but also for compliance, quality reporting, and patient care continuity.
Skin substitutes continue to play a critical role in the treatment of chronic wounds, and there are more products available today than ever before. Although Medicare Administrative Contractors have slowly started to spell out their coverage criteria for skin substitute grafts used to treat certain conditions, progress has been slow.
According to the National Multiple Sclerosis Society, almost one million people in the United States have been diagnosed with multiple sclerosis (MS), a chronic autoimmune neurological disorder. Discover how to code the diagnostic tests for MS, the varieties of the disorder, and treatments for it.
The American Medical Association recently issued its 2026 CPT code set, which includes 288 new codes, 84 deletions, and 46 revisions. Review the changes to ensure proper procedure coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Like previous federal government shutdowns, the one that ensued when Congress failed to produce a continuing resolution on the budget by October 1 has implications for providers. You should reduce the chances of harm by planning to address them now.
Changes are being made to the ICD-10-CM conventions, general guidelines, and chapter-specific guidelines for fiscal year 2026, which will be effective October 1, 2025. This article summarizes some of the changes coders need to be aware of.
Q: The 2026 ICD-10-CM code update, effective October 1, 2025, has new codes for flank tenderness (R10.8A-) and flank pain (R10.A-). What's the difference between pain and tenderness?
Medicare coverage of mental health services has expanded in recent years. Along with authorizing payment for additional services and telehealth options, CMS has established several new provider types. Steps have been made to expand access to care, but many healthcare facilities are still working to establish a solid foundation in CPT coding for mental health services.
Updated coding guidance can be found in CMS’ Medicare Preventive Services educational tool for several services. Review the changes to ensure proper coding of preventive services.
Changes are being made to the ICD-10-CM conventions, general guidelines, and chapter-specific guidelines for fiscal year 2026, which will be effective October 1, 2025. This article summarizes some of the changes coders need to be aware of.
Medicare pays for therapy services when the medical record and the information on the claim form accurately report covered therapy services. That means your documentation must be legible, relevant, and sufficient to justify the services billed. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
According to the National Multiple Sclerosis Society, almost one million people in the United States have been diagnosed with multiple sclerosis (MS), a chronic autoimmune neurological disorder. Discover how to code the diagnostic tests for MS, the varieties of the disorder, and treatments for it.
The implementation of the 21st Century Cures Act has resulted in radiology patients in the outpatient setting being able to view their examination results quicker, according to a study published in JAMA Network Open.
The pelvis encloses and supports the internal organs, so a pelvic ring fracture—commonly caused by traumatic events such as car crashes—can trigger extensive internal bleeding and other injuries. Learn about some CPT fracture codes for posterior pelvic ring fractures that would be reported in many trauma situations.
The Outpatient Code Editor (OCE) provides the answers to the test, but to use it effectively, you need to understand the history and the complex configuration of all the parts.
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
Machine learning (ML) has evolved beyond its status as a technological trend to become an indispensable asset in outpatient surgical risk stratification. Within the domains of medical coding and claims adjudication, coding professionals play a pivotal role in optimizing ML model performance.
With takeaways from three certified medical professionals, HIM professionals can discover how the complexity of care for major depressive disorder impacts decisions around admissions, treatment intensities, resource allocations, and service quality, beginning with outpatient care.
The Outpatient Code Editor provides the answers to the test, but to use it effectively you need to understand the history and the complex configuration of all the parts.
A study published in Respiratory Care found that integrating respiratory therapists (RT) in a chronic obstructive pulmonary disease (COPD) clinic led to significant improvements in symptoms and exacerbation rates among patients, as well as a reduction in hospitalizations.
CMS recently updated its July 2025 update to the Ambulatory Surgical Center Payment System to include several new HCPCS codes and revised information about coding for drugs, biologicals, and radiopharmaceuticals. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Are you passionate about sharing your knowledge and looking to make an impact in medical coding? Are you an experienced coding professional with inpatient, outpatient, pro-fee, specialty, or...
CMS recently published the fiscal year (FY) 2026 ICD-10-CM Official Guidelines for Coding and Reporting to accompany the ICM-10-CM update that will be effective October 1, 2025. The guidelines include clarifications and revisions to several areas that coders should note.
Prepare now for 21 code revisions that coders will find in the 2026 CPT manual by reviewing changes in the proposed 2026 Medicare physician fee schedule.
The most common ankle tendon repair is for the Achilles tendon, the largest and strongest tendon in the body. Brush up on the CPT codes for repair of this tendon. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Machine learning (ML) has evolved beyond its status as a technological trend to become an indispensable asset in outpatient surgical risk stratification. Within the domains of medical coding and claims adjudication, coding professionals play a pivotal role in optimizing ML model performance.
Make sure your providers are showing the mental work that goes into evaluating the risk associated with a medication before you count it toward the risk element of an E/M visit that is coded based on medical decision-making.
The second quarter edition of Coding Clinic included questions and answers for coding very specific situations not easily found using the Alphabetic Index. Review some of the noteworthy scenarios.
Physical, occupational, and speech therapy are the most common types that people think of when therapy is recommended. However, there is a new type gaining momentum: pelvic floor therapy.
Our experts answer questions about independent historians, the number and complexity of problems addressed at an encounter, and counting discussion of management.
To make sure your ICD-10-CM codes are correct and complete, you may need to use an X as a placeholder to expand the code to the proper length. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The proposed 2026 Medicare physician fee schedule, released July 14, boosts the Part B conversion factor for calendar year 2026, adds billing opportunities for behavioral health services, previews new codes, and updates the agency’s quality reporting programs.
Q: What if a provider sends a summary of their visit with a patient to the patient’s primary care provider. Is this considered a “discussion” of patient management?
The calendar year 2026 OPPS and ambulatory surgical center (ASC) proposed rule, released on July 15, details payment updates, services covered, outpatient service volume, and quality reporting, among other proposals.
Physical, occupational, and speech therapy are the most common types that people think of when therapy is recommended. However, there is a new type gaining momentum: pelvic floor therapy.
Practices turned to two of the X-series modifiers in place of modifier -59 (Distinct procedural service) more than 7 million times in 2023 and saw mixed results with denial rates on the top-billed codes.
Medicare considers the shoulder to be “a single anatomic structure,” according to the National Correct Coding Initiative policy manual. In this article, find out what that means from a coding standpoint. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The second quarter edition of Coding Clinic included questions and answers for coding very specific situations not easily found using the Alphabetic Index. Review some of the noteworthy scenarios.
Q: What’s the difference between CPT code 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services)?
CMS recently released the fiscal year (FY) 2026 ICD-10-CM update, which includes 487 new diagnosis codes effective October 1, 2025. The new codes cover a range of diagnoses, so be sure to review the code update files.
With advancements in artificial intelligence (AI) and augmented intelligence enabled healthcare, the American Medical Association provided guidance outlined in Appendix S taxonomy for describing and classifying various AI applications. This article will help coders understand the AI taxonomy.
We are just entering summertime and meteorologists are already warning about increased heat indexes all over the country. Staying hydrated is important advice because serious maladies can take place when the body becomes dehydrated.
Our experts answer questions about medical decision-making, locating procedure codes, and coding a revision of a unicompartmental knee arthroplasty to a total knee arthroplasty.
Review the FY 2026 ICD-10-CM tabular addenda for codes that you regularly report so you don’t miss additional information that can augment coding through more guidance or alert you to potential pitfalls.
Pain management providers primarily perform radiology services from the diagnostic imaging and radiologic guidance sections of the CPT code book, so specialty coders must know when these services can be separately reported and their documentation requirements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
We are just entering summertime and meteorologists are already warning about increased heat indexes all over the country. Staying hydrated is important advice because serious maladies can take place when the body becomes dehydrated.
Make sure you incorporate current CMS coding guidance for three preventive services into your workflow and check for denials that might be candidates for an appeal. Review the latest rules for HIV PrEP, hepatitis vaccine, and CRC screens.
CMS developed medically unlikely edits (MUE) as a way to limit the number of times a particular service is allowed to be billed by a single provider to a single patient on any given date of service. This article explains how MUEs can be used to stop errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Clients who participated in court-ordered assisted outpatient treatments (AOT) displayed significant improvements across several outcome measures, according to a study recently published in Psychiatric Research and Clinical Practice.
When a physician requests a consult from another physician, how can medical coders tell if the conversation counts toward the data review column in the medical decision-making table? This article provides guidance on when to count those conversations.
With advancements in artificial intelligence (AI) and augmented intelligence enabled healthcare, the American Medical Association provided guidance outlined in Appendix S taxonomy for describing and classifying various AI applications. This article will help coders understand the AI taxonomy.
Effective October 1, 2024, three new diagnostic codes have been added to the ICD-10-CM classification system. These three new codes are designed to capture early stage type 1 diabetes preceding the onset of symptoms.
Start training your staff on the diagnosis code changes that will go into effect October 1. CMS will adopt the ICD-10-CM additions, revisions and deletions that it previewed in April. This article highlights some of the changes you should note.
The first quarter edition of Coding Clinic included new and revised guidelines, a change to the Alphabetic Index, and a question and answer section which discusses complicated coding issues. This article highlights noteworthy changes.
Our experts answer questions about coding breast implant-associated anaplastic large cell lymphoma, medical necessity documentation, and anesthesia coding for knee surgery.
A recent study published in the American Journal of Psychiatry looked into national trends in outpatient mental healthcare and found that the use of psychotherapy increased while the use of psychotropic medication alone decreased.
The first quarter edition of Coding Clinic included new and revised guidelines, a change to the Alphabetic Index, and a question and answer section which discusses complicated coding issues. This article highlights noteworthy changes.
Modifier -25 is used to report a significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Make sure your staff know when they can count the independent review of a test toward medical decision-making. This article provides guidance on when to count independent interpretations.
Medicare utilization of CPT critical care code 99291 and add-on code 99292 jumped higher during the pandemic years. That bump has subsided, however, and a review of 10 years of progress in critical care utilization suggests the codes have swiftly adjusted to pre-COVID levels.
CMS recently updated the list of preventive service codes that can be reported with complexity add-on HCPCS code G2211. In a recent change request, CMS deleted codes for services not considered covered preventive services and added codes for services that are considered covered preventive services.
Effective October 1, 2024, three new diagnostic codes have been added to the ICD-10-CM classification system. These three new codes are designed to capture early stage type 1 diabetes preceding the onset of symptoms.
There are three ways to bill the services of a non-physician practitioner: incident-to, direct, and shared billing. The type of billing used often depends on the location of service and the degree of physician supervision. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
