Some people read mystery novels, some people can read body language but medical coders can read claims. Some claim lines are simple to read. The patient comes into a physician office, has an office visit for asthma treatment. A single CPT® code and a single diagnosis code is all she wrote. If the patient also […]
Archives for March 2017
Documenting History | Evaluation and Management Services
Lunch and Learn What does a clinician need to document in the history? Is it okay to say, “non-contributory”? What if the medical assistant takes the HPI and the physician or nurse practitioner notes that it was reviewed? This short video addresses the documentation guidelines for the History component of evaluation and management services including, […]
Meatloaf Says, “2 Out of 3 Ain’t Bad” | E/M Documentation Guidelines
Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors? Answer: This answer relates to E/M services 99211–99215, and is relevant until Dec. 31, 2020. Then, it is superseded by the CPT E/M definitions. Not according to CMS. Recently, when I was explaining […]
Pessary Billing and Coding
Coding for Pessary Services Primary care practices, gynecology and urology practices often prescribe and provide pessaries. Â A pessary is used to treat pelvic organ prolapse and for urinary incontinence. It provides support for the vaginal walls, uterus, bladder or rectum. A physician or non-physician practitioner (NPP) must first see the patient, take a history, examine […]
Wondering About Transitional Care Management?
A Video Overview of TCM Codes Finally, payment for services practices typically do for free! Transitional Care Management (TCM) provides payment to medical practices for helping complex patients transition from a facility to a non-facility setting, for example, from the hospital to home. It pays for the provider and clinical staff to perform non-face-to-face services […]