Q: How does CPT ® define "final examination" for code 99238 (hospital discharge day management; 30 minutes or less)? Does the dictation have to include an actual detailed examination of the patient? We have been coding 99238 for discharges that include final diagnosis, history of present illness, and hospital course along with discharge labs, medicines, and home instructions. Very few contain an actual exam of the patient. Have we been miscoding all this time?
Codes for OB/GYN haven’t changed much recently, but some diagnoses still confuse coders. Glade B. Curtis, MD, MPH, FACOG, CPC, CPPM, CPC-I, COBGC , and Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, review some top areas of concern and walk through case studies to explain those problems.
Coding for podiatry services requires an extensive understanding of complex anatomy and regulations. Lynn M. Anderanin, CPC, CPC-I, COSC , AAPC Certified ICD-10-CM instructor, AHIMA Approved ICD-10-CM trainer, reviews what steps coders can make to ensure complete documentation for podiatry services that are facing increasing audits.
New CPT ® codes introduced for 2014 will give healthcare providers new ways to report pain management services and treatments. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer , reviews some of the codes, including new evaluation and management and Category II codes.
Like the skin, dermatology coding has several layers. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, says that coders need to pay attention to the type of procedure, site, size, and more in order to accurately report each encounter.
Modifiers are sometimes essential to ensure proper payment, but choosing the correct one can be tricky. Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS; Katherine Abel, CPC, CPMA, CEMC, CPC-I; and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, discusssome confusing modifiers and how to use them accurately.
Medical necessity establishes the foundation for evaluation and management (E/M) code selection and supports the need to services provided to the patient. Peggy Stilley, CPC, CPMA, CPC-I, COBGC, ACS-OB , and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-approved ICD-10-CM/PCS trainer, explain how to define, determine, and defend medical necessity for E/M codes.
The AMA significantly changed how coders report cervicocerebral imaging in 2013. Andrea Clark, RHIA, CCS, CPC-H, and David Zielske, MD, CIRCC, CPC?H, CCC, CCS, RCC, discuss the changes and provide tips for coding these services.
Coding debridement of ulcers requires that coders know the type, location, and depth of the ulcer and the treatment provided. Gloria Miller, CPC, and Robert S. Gold, MD, review the clinical and coding aspects of ulcer debridement.
Outpatient providers are beginning to see more and more medical necessity audits, especially in the ED and for evaluation and management (E/M) levels. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer, and Joanne M. Becker, RHIT, CCS, CCSP, CPC, CPC-I, AHIMA approved ICD-10-CM/PCS trainer, review the guidelines for ED E/M services and highlight common audit risk areas.
Even experienced coders struggle to determine when to append modifiers -58, -78 and -79 because they are very similar in definition, but very different in scope and usage. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reveals the nuances coders must understand to correctly use these modifiers.
To correctly code for radiation oncology services, coders need to understand the various elements of the treatment. Rebecca Vandiver, CPC, CPC-I, and Chandra Stephenson, CPC, CPC-H, CPMA, CPC-I, CANPC, CEMC, CFPC, CGSC, CIMC, COSC, analyze these complex services from a coding perspective.
Anesthesia coding in some ways is similar to evaluation and management coding—only easier. Chandra Stephenson, CPC, CPC-H, CPMA, CPC-I, CANPC, CEMC, CFPC, CGSC, CIMC, COSC, explained the 10 steps to coding anesthesia during the AAPC National Conference in Orlando, Fla., April 14-17.
At first glance, the new CPT ® codes for reporting molecular pathology services might seem simple. They certainly look easier than the old stacking codes that focused on methodology and processes, resulting in multiple codes and quantities being used to report a single test. Jugna Shah, MPH, and Michelle L. Ruben, detail some of the nuances of correct code assignment for molecular pathology tests.
With no national guidelines in place for facilities to use to determine evaluation and management (E/M) level, coders must apply their facility’s guidelines when coding an outpatient visit. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Joanne M. Becker, RHIT, CCS, CCS-P, CPC, CPC-I, use three ED case studies to highlight potential pitfalls for ED E/M leveling.
Breast biopsies should be easy to code because coders have so few codes to assign, but it is one area where documentation is lacking. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, reveals what key elements coders should look for in a breast biopsy note.
Evaluation and management (E/M) coding is incredibly subjective. Two coders can look at the same documentation and choose two different E/M levels and both will be able to justify their choice. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer , Lori Owens, RHIT, CCS, and Deborah Robb, BSHA, CPC, discuss how electronic medical records can complicate E/M coding even more.
Genetic screening is often used to detect abnormal genes or possible fetal anomalies during antepartum care. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews some of the most common genetic tests and what diagnosis codes to report.
Interventional radiology cases are often complex with confusing coding rules, especially for radiologic supervision and interpretation. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, and Karna W. Morrow, CPC, RCC, CCS-P, lead you through the maze of coding these procedures.
One of the major changes to the 2013 CPT ® Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" in a wide range of codes. Marie Mindeman and Andrea Clark, RHIA, CCS, CPC-H, discuss how this change affects code assignment.
