In 2017, CMS developed a HCPCS code, G0505, for cognitive assessment of patients with a cognitive impairment. This code was replaced in 2018 with CPT® code 99483. G0505: Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the […]
Wound Care | CPT® Codes for Debridement
Health care organizations have started wound care clinics to care for patients with non-healing wounds and frequently use wound care debridement codes to report the services. The care of a post-op wound is done by the surgeon in the global period, and is not separately paid, unless it is on-going and the care for the […]
Quick Coding Reference Sheet – E/M Services
This quick reference coding guide to E/M services covers consults, initial and subsequent hospital visits, and observation. This essential resource from CodingIntel includes: CPT® E&M codes for each of the above categories, documentation requirements, MDM examples, and more.
Quick Coding Reference Sheet – Psychiatry
These quick reference sheets for evaluation and management services cover inpatient and outpatient consults, and inpatient and subsequent hospital services. Specifically for psychiatry, this essential resource includes: CPT® codes for each of the above categories, documentation requirements, MDM examples, and more…
This Practice Paid Medicare $4.48 Million
Do you sign up for email lists and then wonder why you did it? We all do, don’t we? But, one email I always read is from the Department of Justice that links to a description of actions, settlements and indictments related to health care billing and coding A few years ago, an Orthopedic practice […]
Modifier 57
Decision for Surgery. An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. The payment for major surgery includes E/M services provided on the day of and the day before a major surgical procedure, unless it […]
Psychotherapy Coding Changes
Words removed from one set of codes, time added to another code. There are two changes in the psychiatry section of CPT® for 2017 behavioral health billing. The first is the description of psychotherapy CPT® codes were revised to remove the words “and/or family.” In 2016, CPT® code 90832 was defined as “Psychotherapy, 30 minutes […]
Medical Decision Making | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023. This article does not apply to services performed after 1-1-2023. Definition Medical decision making (MDM) is one of the three key components of evaluation and management services. (Make sure you read about […]
Global Surgical Package: An Overview
Need a quick summary of the global surgical package and frequently used modifiers? This article from CodingIntel will ensure that your medical practice gets paid correctly for services that are performed. This article includes Definition of the global surgical package Explanation of global surgery billing Explanation of “separate procedure” Global surgery billing and coding rules […]
Modifier 24
Understanding E/M modifiers is important for both revenue and compliance. Failing to apply the correct modifier reduces revenue. Applying the wrong modifier or using it when it is not accurate is a compliance issue and puts the practice at risk for payback and disclosures. For additional information, see the article on Global Surgical Package. Modifier […]
Moderate or High MDM – General Surgery
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023. This article does not apply to services performed after 1-1-2023. Examples of Moderate MDM: Codes: Consult, 99244, Initial hospital 99222, Initial OBS 99219, 99235, ED 99284 Patient presents with a […]
Coding Guide – Global Surgery
This guide from CodingIntel explains surgery coding guidelines and the global period for procedures, and includes the contents of our original CPT® and HCPCS Modifier Guide.
Billing Admission and Subsequent Visits for Patient Having Surgery
What if I admit a patient and don’t take the patient immediately to surgery? Can I bill for the admission and subsequent visits if the patient goes to surgery later in the week? In this case, it depends on when you admit the patient and when the final decision for surgery is made. A major […]
Teaching Physician Rules and Surgical Procedures
The teaching physician rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident, or fellow, in an approved graduate medical education program (GME). The teaching physician’s presence and participation is required. The rules regarding participation and documentation vary by the type of […]
Teaching Physician Rules – Use Modifier GC
Coding. Why does it keep changing? The information you are looking for has moved. Please see the following resources for up-to-date information on the new teaching physician rules and modifier GC: Teaching Physician Rules-Surgical Procedures Teaching Physician Rules – Evaluation and Management Services Revised, Betsy Nicoletti 5/4/19
Laceration Repair
Wound repair is classified as Simple, Intermediate or Complex Simple: 12001—12021 Intermediate: 12031—12057 Complex: 13100–13160 Simple repair: Use when the wound to superficial involving primarily epidermis, dermis or subcutaneous tissue Simple one layer closure Includes local anesthesia, and chemical or electro cauterization of wants not closed Download the minor surgical services billing guide for RVU […]
Three Key Components of E/M Services
There are three key components to evaluation and management services. History, Exam and Medical decision making. Each component has specific rules and documentation requirements. This downloadable article includes definitions, codes, billing guidelines, helpful reference charts and more for each of the three components. COURSE E/M auditing in depth is one of three courses offered by CodingIntel. […]
Reporting Screening Colonoscopy
What is the difference between a screening and diagnostic colonoscopy, and how are they coded? What if a screening colonoscopy was scheduled, but a diagnostic or therapeutic colonoscopy was performed? What you need to know about reporting for colonoscopy procedures in about 10 minutes. See also: Diagnosis coding for screening colonoscopy Procedure Coding for Colonoscopies […]
Why You Shouldn’t Automatically Bill an E/M with Every Procedure
Should you bill just a procedure? Or an E/M service with it? Medicare provides a breakdown by CPT® code of the pre-evaluation, pre-operative, intraoperative, and post-operative times included in each code. Find out more in this 5 minute video. After watching, check out this article for additional information. And download the time file referred to […]
Certification for Home Health Services
There are two HCPCS codes that physician, nurse practitioners, clinical nurse specialists and physician assistants can use to report developing a plan for a Medicare patient who requires home health services. The CARES Act passed in March 2020 permanently allows nurse practitioners, clinical nurse specialists and physician assistants to certify and re-certify Medicare covered home […]
Not all Unspecified Codes are Created Equal
What kind of unspecified codes can a practice still use? Which ones need to be avoided? Quick, five minute guidance in this video about unspecified codes in ICD-10. Relevant Search Terms:diagnosis codes, NCD, LCD, procedures, labs, diagnostic testing
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