The title makes it all clear, right? No? I didn’t think so. This article is an overview of CMS’s Ambulatory Specialty Model. CMS is implementing a mandatory, disease-specific reporting model beginning in the CY 2027, reporting due March 31, 2028. Who will be required to report? And for what conditions? Physicians who work in the […]
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Spotlight on up-to-date coding
Telehealth Visit with a Patient at Home: Office Visit or Home Visit?
CPT® codes for patients at home in a residence: New patient: 99341, 99342, 99344, 99345 Established patient: 99347−99350 These codes are used to report services in a patient’s home or in a residence. “Home may be defined as a private residence, temporary lodging, or short -term accommodation (eg, hotel, campground, hostel, or cruise ship).” These […]
The Prime Directive of HCC coding
The Department of Justice, Office of Public Affairs released a notice on Jan. 14, 2026 stating that the government had entered into a settlement with Kaiser Permanente, et al for false claims related to HCC coding. The government contended that Kaiser had overbilled CMS by a billion dollars over a nine-year period. Kaiser agreed to […]
The Ideal Audit Review Meeting
Do you hope for the perfect audit review meeting? You audit an entire team of providers who either have 100% accuracy or they don’t, but they greet your feedback with grace and humility. It helps when you of direct communication and real curiosity and engagement with the medical team, but results are not guaranteed. Auditing […]
Coding vs. Clinical Validation
Understanding Distinct Roles, Responsibilities, and Qualifications in Healthcare Documentation Two critical functions are often misunderstood or conflated: medical coding and clinical validation. While both are essential to accurate documentation, appropriate reimbursement, and regulatory compliance, they are fundamentally different disciplines that require distinct skill sets, credentials, and areas of expertise. Confusing these roles—or allowing one professional […]
Depression Coding and Hierarchical Condition Coding (HCC)
Introduction | Depression coding in HCC In fee-for-service medicine: Diagnosis coding establishes the medical necessity for a service. At times, it may be the reason for a denial, particularly for diagnostic tests or procedures. Services with national or local coverage policies often have specific diagnosis codes that are required for payment. In V28 of HCC, […]
E/M Frequency Data for Dermatology
For dermatologists, revenue in the office is generated by procedures and office visits. Often, both are provided on the same day. See the dermatology section of our specialty page for articles about the use of modifiers 25, 51, and 59. Frequency distribution for new and established patients 2024 E/M data released at the end of […]
E/M Frequency Data for Surgical Specialties
CMS releases E/M frequency data annually. A physician self-elects their specialty designation when enrolling with Medicare. Unfortunately, there aren’t specialty designations for breast, bariatrics, or trauma surgery, and those surgeons are usually enrolled using the category for general surgery. There are specialty designations for vascular surgery, plastic surgery, thoracic, and surgical oncology. The data below […]
E/M Frequency Data for Psychiatrists
CMS releases E/M frequency data annually. A physician self-elects their specialty designation when enrolling with Medicare. This is the data for psychiatrists. The data below is from 2024 released in late 2025. Office services Psychiatry New OV 2024 99202 0.74% 99203 8.05% 99204 38.58% 99205 52.63% Established office visits 2024 99211 0.73% 99212 4.33% 99213 […]
E/M Frequency Data for Infectious Disease, Pulmonary Medicine and Cardiology
CMS releases E/M frequency data annually. A physician self-elects their specialty designation when enrolling with Medicare. Infectious disease, pulmonary medicine and cardiology are all specialties with active inpatient services, and of course, busy office services. That’s why I’ve elected to show them together. The data below is from 2024, released in late 2025. Office services […]
Removal of a Foreign Body
Integumentary 10120 Incision and removal of foreign body, subcutaneous tissues; simple 10121 Incision and removal of foreign body, subcutaneous tissues; complicated Note that incision is required. Musculoskeletal From Principles of CPT® Coding, “If fascia is penetrated and a foreign body to be removed is within the fascia, subfascia or muscle, use an anatomic-specific code in […]
Remote Physiologic Monitoring Treatment Management Services
The remote physiological monitoring section describes providing equipment and data collection, initial set up and education on the use of the equipment, and treatment management based on the data that was measured. The codes are confusing because they are sorted/divided in confusing ways. Codes 99453, 99445 and 99454 are for the initial set up and […]
Remote Therapeutic Monitoring
There are two sets of codes in the CPT® code set for Remote Therapeutic Monitoring (RTM). The first set is for the monitoring itself, and includes codes for initial set-up and patient education and for the device supply or data transmission. The second set of codes is for treatment management services based on the data […]
Diabetes Coding in Hierarchical Condition Coding (HCC)
Diabetes is a common chronic condition, included in three distinct HCC categories Patients often have more than one chronic condition of the disease; page down for a Q&A related to how multiple conditions do–and don’t–affect the risk score CodingIntel members can download our guide to Risk Adjusted Diagnosis Coding for Medical Practices for more explanation and […]
Consent for Communication Technology-Based Services (CTBS)
Both CPT® and CMS have developed codes for non-face-to-face communication-based technology services (CTBS) in recent years. In addition to care management services, these include interprofessional consults, remote physiologic and therapeutic monitoring, and on-line digital E/M services In the 2020 Physician Fee Schedule Final Rule, CMS clarified the type of patient consent that is required to […]
Commonly Performed Procedures in Primary Care | Reference Sheet
These reference sheets for minor procedures include common CPT® codes, descriptions, current work and non-facility RVUs, and global days for quick reference. The first chart includes codes 10060-11443, the second 11600-17111, and the third 20550-54056.
Critical Care for General Surgery and Trauma Surgeons
Critical care provided as a stand-alone service is based on the seriousness of the patient, the types of intervention, and time spent in direct patient care. Critical care provided by a surgeon to a patient in a global period for procedures with a 10- or 90-day global period, must also follow the rules for critical […]
Coding for Medical Nutrition Therapy Services
Medical Nutrition Therapy Services (MNT) have been a covered benefit under Medicare since the early 2000’s. This article will describe the rules related to coding for medical nutrition therapy services for Medicare patients. This article also addresses common questions about coverage under the Medicare benefit with brief answers and links to the source documents for […]
Outpatient Diabetes Self-Management Training (DSMT) Services
Medicare covers diabetes self-management training (DSMT) services are a covered benefit under Medicare when all requirements are met. This article will provide an overview of the requirements and provide answers to some commonly asked questions. It will also provide you with links to the source material for DSMT coverage in the CMS Medicare Benefit Policy […]
Consultation Codes
CMS stopped recognizing consult codes in 2010. Outpatient consultations (99242—99245) and inpatient consultations (99252—99255) are still active CPT® codes, and depending on where you are in the country, are recognized by a payer two, or many payers. In 2023, codes 99241 and 99251 were deleted. These two low level consult codes were rarely used. There […]
The Second Element of MDM: Amount and/or Complexity of Data
There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. This article describes the definitions […]
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