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, the clinician must document time in the medical record. Examples of this are: some psychiatry codes certain physical therapy modalities critical care services the second level discharge visit prolonged services When you look at the definition of a CPT code, if time is listed, … [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 discussing various diagnostic/therapeutic procedures, the risks and benefits and whether to consider surgery. Recently I had a 99215 challenged. I documented >40min more than 50% in face-to-face counseling and detailed all of the matters discussed. I was told it should be down-coded to 99214 … [Read more...]
Coding for Hospitalists
Coding for services done by hospitalists and other specialty physicians in the hospital can be confusing. After watching these videos and downloading the guides, you'll be confident that you are selecting the right category of code and level of service. The third video discusses critical care and prolonged inpatient services. These are great for newly hired hospitalists or coders that code for them. Each is about 12 minutes long, so they'd … [Read more...]
Quick Coding Cheat Sheet – E/M Services
E/M Cheat Sheet with Evaluation and Management Codes This quick E/M cheat sheet for evaluation and management services covers office visits, 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 Time thresholds and more important information on evaluation and management codes … [Read more...]
Quick Coding Cheat Sheet – Psychiatry
This quick reference sheet for evaluation and management services covers office visits, consults, initial and subsequent hospital visits, and observation. Specifically for psychiatry, this essential resource includes: CPT codes for each of the above categories Documentation requirements MDM examples Time thresholds and more… … [Read more...]
Can I code at a higher level if everyone in the exam room is crying?
This short video addresses your questions about coding a higher level of service due to patient behavior. Includes CPT guideline, tips on selecting level of service, and documentation requirements... … [Read more...]
Definitive Guide to Documenting Time
Office visits, inpatient care, prolonged services, critical care...properly documenting time can help ensure that you receive the maximum allowable payment for the time you spent with the patient. Use this handy reference guide to make sure your documentation includes all the necessary components. … [Read more...]
Your Patient Wants to Talk: How to Bill for Discussion Visits
Does the phone in your office ring off the hook when medical news hits google’s landing page? The bubble above your patient’s head reads, “Do I need a statin?” “To mammogram or not to mammogram?” “Is hormone replacement therapy really that bad for you? Because I can tell you, my nights are awful.” And, when these patients meet with the doctor or other provider they say, “I don’t need to be examined. I just want to talk with her.” As if … [Read more...]