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Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

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Describe the exam | E/M services for dermatology

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...]

Last revised: March 18, 2019
by Betsy Nicoletti
Tagged With: Dermatology coding, Documentation Guidelines, E/M services, exam

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 … [Read more...]

Last revised: February 11, 2019
by Betsy Nicoletti
Tagged With: E/M services, using time to select a code

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...]

Last revised: February 11, 2019
by Betsy Nicoletti
Tagged With: audit, E/M services

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...]

Last revised: March 18, 2019
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services, exam, MDM

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 … [Read more...]

Last revised: March 18, 2019
by Betsy Nicoletti
Tagged With: E/M services

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...]

Last revised: October 4, 2018
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services, exam

Coding Guide – How Physician Services are Paid

Table of Contents CPT® HCPCS Modifiers NCCI Multiple procedures Fee calculation Global surgical payment Diagnosis … [Read more...]

Last revised: May 22, 2019
by Betsy Nicoletti
Tagged With: CMS, CPT®codes, E/M services, HCPCS, ICD-10, Medicare rules

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...]

Last revised: November 26, 2019
by Betsy Nicoletti
Tagged With: CMS, E/M services, HCPCS codes

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...]

Last revised: September 13, 2018
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services, emergency services, medical decision making

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...]

Last revised: October 12, 2018
by Betsy Nicoletti
Tagged With: CPT® rules, E/M services, minor procedures, Modifier 25

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...]

Last revised: October 12, 2018
by Betsy Nicoletti
Tagged With: CPT® rules, Documentation Guidelines, E/M services, Medicare rules, using time to select a code

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...]

Last revised: March 18, 2019
by Betsy Nicoletti
Tagged With: category of code, E/M services, new patient

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...]

Last revised: June 25, 2019
by Betsy Nicoletti
Tagged With: audit, Documentation Guidelines, E/M services

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...]

Last revised: June 25, 2019
by Betsy Nicoletti
Tagged With: consults, Documentation Guidelines, E/M services, established patient, modifiers, new patient, prolonged services

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...]

Last revised: April 4, 2019
by Betsy Nicoletti
Tagged With: CPT® rules, Documentation Guidelines, E/M services, MDM

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...]

Last revised: June 13, 2019
by Betsy Nicoletti
Tagged With: CPT® rules, Documentation Guidelines, E/M services

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...]

Last revised: June 1, 2017
by Betsy Nicoletti
Tagged With: CPT®codes, E/M services, Physician Billing

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...]

Last revised: April 4, 2019
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services

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...]

Last revised: October 15, 2018
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services, medical decision making

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...]

Last revised: April 23, 2019
by Betsy Nicoletti
Tagged With: Documentation Guidelines, E/M services, psychiatry, using time to select a code

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CPT® Coding Changes for 2020 | Webinar

December 12, 2019 @ 12:00 pm (EST) Learn … Read More...

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Coders crave certainty We coders don’t just … Read More...

CMS’s 2020 Physician Fee Schedule Final Rule | Webinar

Recorded November 21, 2019 CMS released the … Read More...

Non-physician practitioners in nursing facilities

Question: Can a physician assistant see … Read More...

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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