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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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 announced its A/B Medicare administrative contractors have withdrawn the local coverage determinations for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers.
Use the documentation “cross-out test,” clinical vignettes, and expert answers to scenarios to educate staff about when they can and cannot unbundle an evaluation and management visit from a same-day procedure.
Medicare pays for physical and occupational therapy services when the medical record and the information on the claim form accurately report covered therapy services. This article discusses Medicare’s documentation requirements to justify billed therapy services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As we approach the end of the year, take a moment to refresh yourself on the ins and outs of the primary code sets an outpatient coder needs to understand and use in their role. This article provides a brief overview of three code sets that will serve as a review for veteran coders or a solid base of information for new coders.
After a few years of confusion about how providers should document time for level-based evaluation and management services, the consensus can be summarized as “make it make sense,” according to a review of guidance issued by all seven Medicare administrative contractors.
Accurate provider documentation is the foundation of compliant coding, appropriate reimbursement, and defensible claims. Yet, in a rapidly changing healthcare landscape, even highly skilled clinicians can find it difficult to stay current.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
