Advance Care Planning CPT® Codes Overview Medical practices perform countless tasks every day for which there is no payment. CMS continually states that it wants to support non-procedural and in the past decade has added payment for some non-face-to-face services, including Care Plan Oversight, Transitional Care Management and Chronic Care Management. CPT® Codes 99497 & […]
Chronic Care Management: Benefit Update
Coding. Why does is keep changing? This post was out of date and has been removed. For information about chronic care management and other care management services, see these resources: Chronic care management services (CCM), CPT® 99491 Chronic care management Behavioral health integration and CCM codes Or Browse the resource library by topic, keyword, or code […]
Pecked By a Parrot. Oh No, Not Again!
When we first implemented ICD-10, we all had a lot of fun with the ICD-10-CM external cause codes. But, do we need to use them? The answer to that is no according to the official guidelines and yes if your payers require them. Here is what the official ICD-10-CM guidelines say, “There is no national […]
Prescription Drug Management and Medical Decision Making (MDM)
Whether selecting a level of service for an E/M encounter, the question arises about what counts as prescription drug management. In both sets of guidelines, it appears in the moderate medical decision making (MDM) row. The question arises, should we credit prescription drug management for new prescriptions, medication adjustments, and renewals? My answer has always […]
Skype ≠ Telemedicine
I got a call from a vendor trying to develop a video conferencing product for a physician to use to talk to a patient who is at home. He said “I’m having trouble finding codes for telemedicine that the doctor can use.” Aren’t we all. Talking to your patient using a secure video connection doesn’t […]
Cloning: I Read the News Today, Oh Boy.
Certain medical stories are irresistible to the popular press: ICD-10 external cause codes that are ridiculous (W61.43XD, pecked by a turkey, subsequent encounter) or medical practices using their electronic health records in a way that increases their revenue. A recent headline was eye-catching, as headlines are meant to be, “Report finds more flaws in digitizing […]
There’s No Place Like Home, but Everyone Likes to Get Out Once in a While | Eligibility for Home Health Services
In order to be eligible for Medicare covered home health services a patient must be considered home bound. But what does that mean? That the patient can never leave the house? Doesn’t generally leave the house? Is like a Vermonter in a snow storm, and doesn’t see the point of leaving the house? CMS recently […]
Coding for Screening Colonoscopy
Table of Contents An Overview of Colonoscopy Coding Guidelines Screening Age and Non-invasive Coverage Screening Colonoscopy for CRC What is the Difference Between a Screening Test and a Diagnostic Colonoscopy? Two Sets of Procedure Codes are Used for Screening Colonoscopy E/M Service Prior to a Screening Colonoscopy Screening Colonoscopy for Medicare Patients that becomes Diagnostic […]
No Chart Left Behind: Deadline to Complete Medical Records
Years ago, I worked with a physician who was chronically behind in dictating his notes. The charts were crammed into boxes by date, lining the walls of his office. Sometimes, they flowed over into the hallway or into the break room. This caused major inconveniences when a patient called for a lab result or returned […]
The Physician Who Never Sleeps: Using the Correct NPI
Years ago, I worked with an Orthopedist who needed hours less sleep than I or the average person needed. While it would be incorrect to say he never slept, he woke up early, did his administrative tasks before his wife and kids were awake and arrived for work on time and ready to go. But, […]
Your HPI: It Should Be Longer than a Tweet
The history of the present illness should be longer than a tweet and twice as informative. Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing. Why bring this up in the context of electronic health records? Because too often, the HPI in EMR […]
Avoiding Unforced Errors While Using Your EMR
“I have a normal exam template that I always use.” All right, I know baseball season is over, and it is hunting season in Vermont, so maybe I should title this, “Don’t shoot yourself in the foot.” The government and private payers have cloned notes in their line of vision. And, physicians and Non-Physician Practitioners […]
Less is More: Don’t Let Your EMR Run Away from You
“My medical assistant populates the past medical, family and social history in every note.” Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation. I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we […]
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