Does your practice perform any minor or major procedures? If so, this post is for you! This post relates to the global package, and not to determining the risk of additional diagnostic testing or treatment in an E/M service. Primary care practices and urgent care centers should pay special attention to these issues and avoid […]
What’s the Difference Between B20 and Z21? Which is Right for Positive HIV Status?
In this post ICD-10-CM diagnosis coding for positive HIV status Medical practice reimbursement for individual claims based on CPT® Common HIV diagnosis codes Question: For an HIV positive patient without symptoms, is the correct diagnosis code Z21 or B20? What difference does it make to reimbursement? Answer: Following ICD-10 guidelines, a patient with HIV status […]
History | 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 History is one of the three key components (history, exam, and medical decision making) of Evaluation and Management Services. […]
Diagnosis Coding for Tick Bites
Question: Why is it so hard to have correct diagnosis coding for tick bites? And, how is it coded? Answer: The search function in electronic health records leads clinicians astray. And, diagnosis coding for tick bites requires two diagnosis codes, because it is an injury. It requires a code from the injury chapter in the […]
Documenting Exam | Evaluation and Management Services
Lunch and Learn Exam is the second key component of evaluation and management services. This short video discusses the requirements for documenting exam, including a review of the 1995 and 1997 Exam guidelines, and what you must document for high level visits. The printable companion resource will be a helpful reference sheet for providers, coders […]
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, […]
Billing for Multiple Surgical Procedures
When billing for multiple procedures on the same day, use this step by step procedure to determine if you should bill for more than one procedure, and if so, if you should use modifier 51 or modifier 59. It is critical to have access to National Correct Coding Initiative ((NCCI) edits in your software program. […]
How to Get Paid for Services in Medical Practices: Three Quick Videos for New Clinicians and Staff
An Overview of CPT® Codes, HCPCS, Diagnosis Codes & ICD-10-CM This three-part series from CodingIntel is a must see for new staff and physicians, and is a helpful review for everyone. Includes modules on How Physician Services are Paid, and the basics of CPT® codes, HCPCS, diagnosis codes and ICD-10-CM. Part 1 – How Physician […]
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 […]
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 […]
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.
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 […]
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 […]
Quick Coding Reference Sheet – General Surgery
This quick reference sheet is packed with useful information. It covers consults, initial and subsequent hospital visits, and observation. Specifically for general surgery, it includes: CPT® codes for each of the above categories, documentation requirements, MDM examples, and more…
Excision of Soft Tissue, Lipoma Removal
This chart is a quick reference for soft tissue excision. It includes anatomic location and size for subcutaneous and subfacial excisions.
Excision of Benign or Malignant Lesions
This article reviews codes and guidelines for excision of skin lesions. For more information about minor procedures, see additional resources at the bottom of this page. This article includes: CPT® Codes for Excision Excision of Benign Lesions Excision of Malignant Lesions Excision of Soft Tumors Reporting Excision of Multiple Lesions of the Same Size Coding […]