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June 5, 2026

Archives for October 2018

CMS E/M Proposal: When Will We Hear?

Checking my crystal ball, my guess is Friday, November 2. Late afternoon. CMS releases its final rule about 60 days before it goes into effect, and this rule’s effective date is January 1, 2019. We are anxiously awaiting their decision about the fate of E/M office codes, payment reduction when modifier 25 is on a […]

CPT® Codes for Fine Needle Aspiration

Fine needle aspiration biopsy Material is aspirated with a fine needle and the cells are examined cytologically. A core needle biopsy is performed with a larger bore needle to obtain a core sample. Use code 10021 for FNA without imaging guidance, first lesion and 10004 for each additional lesions. Use codes 10005 – 10012 for […]

Skin Biopsies

Correctly selecting and reporting skin biopsies requires an understanding of CPT® codes for skin biopsies There are codes for excision of benign and malignant lesions, and codes for shave procedures.  Those are coded based on the size of the excision and location There are specific biopsy codes in other chapters, for biopsy of ears, lips, […]

Exam and Time in a Visit | Documentation Requirements in E/M Services

Question: For an established patient, if I don’t document a physical exam, am I required to say that the visit was a counseling visit and document time? Answer: No. And, it would be incorrect to do so, if counseling did not dominate the visit. Established patients require two of the three key components of history, […]

Coding for Depression in the HCC System | Reference Sheet

HCC diagnosis coding for depression can be confusing. This quick reference sheet simplifes the process with an easy to follow chart. Includes a handy reference to alternate descriptions listed in some EMR’s for relevant ICD-10 codes.

Five Urban Legends About Risk-Adjusted Diagnosis Coding

Originally published on kevinmd.com When I talk to medical practices about Hierarchical Condition Category (HCCs) and risk-adjusted diagnosis coding, I receive a lot of questions that point to the existence of persistent urban legends. Let’s separate fact from fiction. Don’t miss our Billing Guide on Risk-adjusted Diagnosis Coding for an in-depth look at this topic. Urban […]

Coding for Hospitalists

The information in this post applies to services provided PRIOR TO 1/1/2023 Coding for services done by hospitalists and other specialty physicians in the hospital can be confusing.  After watching these videos and downloading the guides, you’ll be confident that you are selecting the right category of code and level of service.  The third video […]

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