What do you need to document for the exam? According to the Documentation Guidelines, exam findings must be documented. It is not sufficient to … [Read more...]
Using Time to Select a Code | Dermatology
Some Evaluation and Management codes, and some other codes are defined by the amount of time of the service. When a CPT code is defined by time, … [Read more...]
E/M in 2019: A look ahead
Now that the dust has settled from the release of the Physician Fee Schedule Final Rule, maybe it’s time for a re-cap. This article will also discuss … [Read more...]
E/M for Dermatology | History, Exam, MDM
Accurately documenting and coding E/M services is critical to reducing compliance risk and maximizing revenue for the evaluation and management … [Read more...]
Remote Physiologic Monitoring Treatment Management Services
2019 brings us three new CPT codes and a revised existing code for remote monitoring and treatment. Here are the four active codes. Two of them have … [Read more...]
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 … [Read more...]
Coding Guide – How Physician Services are Paid
Table of Contents CPT HCPCS Modifiers NCCI Multiple procedures Fee calculation Global surgical payment Diagnosis … [Read more...]
CMS Proposed Changes in the 2019 Physician Fee Schedule Rule | Webinar
Recorded August 16, 2018 Some Fee Schedule rules are almost boring, but not this year! CMS is proposing significant changes to the payment … [Read more...]
Not all emergency surgery should be coded at the highest level | E/M Services and MDM
Surgeons sometimes think that the E/M service on the date of every emergency surgery is the highest level E/M. 99205 or 99285 or 99223. When I … [Read more...]
What does the decision to perform a minor procedure really mean?
I received this question recently and want to share it with you. “Since the decision to perform a minor procedure is included in the payment for the … [Read more...]
Let’s go to the source! Should this visit be downcoded?
A physician asked me this question: “As an interventionalist, a good part of my visit is spent not only explaining patients conditions to them but … [Read more...]
Determining new patient vs. established patient | CPT Rules
Question: A physician wrote: “We have a cosmetic treatment center that is separate from our surgical clinic. I have seen a patient in the cosmetic … [Read more...]
To Credit or Not to Credit: Auditing E/M Services
Recorded September 21, 2017 When it comes to auditing E/M services, there’s black, white and a whole lot of gray. Reasonable auditors can disagree. … [Read more...]
Everything you want (and need) to know about E/M services
Evaluation and Management (E/M) services account for 30% of the revenue paid by Medicare for all physician services. For many specialties, E/M codes … [Read more...]
Medical Decision Making | Evaluation and Management Services
Lunch and Learn Medical Decision Making is the third key component of evaluation and management services. MDM has three components: The number … [Read more...]
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 … [Read more...]
Pessary Cleaning and Re-insertion
Question: Can we bill code 57160 when a patient comes in for a pessary cleaning? Answer: No, report an E/M service based on the key … [Read more...]
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 … [Read more...]
Meatloaf says, “2 out of 3 ain’t bad” | E/M Documentation Guidelines
Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining … [Read more...]
Quick Coding Cheat Sheet – Psychiatry
These quick reference sheets for evaluation and management services cover office visits for new and established patients, outpatient consults, and … [Read more...]