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 […]
Clinical Staff Time
Question: : If a nurse helps with ROS, medication reconciliation, etc., would their time (if documented) be able to be included in the time for the visit?
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 […]
Coding for Observation Services
CPT® Codes for Observation Services There are two sets of codes used for both inpatient status and observation level of care. Coding for observation services no longer has a distinct set of CPT® codes as those were deleted. The “observation care code” applies to Hospital Inpatient or Observation Care Services Codes: 99221–99223 for initial inpatient […]
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 […]
Drug Therapy Requiring Intensive Monitoring for Toxicity
Question: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for toxicity?” Answer: Not from the AMA or CMS. Some MACs or third parties may have lists. Here’s the definition:
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 […]
Diagnosis Coding for Suspected Cancer
Diagnosis coding for possible malignancy When coding for a suspected or possible condition in the outpatient setting, follow the guidelines in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services. “H. Uncertain Diagnosis Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “compatible with,” or “working diagnosis” or other similar terms indicating […]
Wellness Visits in Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs)
RHCs and FQHCs are paid an all-inclusive rate (AIR) or national prospective payment system (PPS) rate for any service that is defined as a visit to their facility. A visit may be with a physician, non-physician practitioner (NPP), psychologist or social worker. There are some differences in RHC and FQHC rules, but in general, a […]
Psychiatric Collaborative Care Management Services
This resource covers Psychiatric Collaborative Care Management Services 99492, 99493, 99494 and
Care Management for Behavioral Health 99484.
Coding Guide – Care Management Services
Updated December, 2025
Coding Guide – Fracture Care Coding Fundamentals
This guide provides rules for reporting fracture care services using CPT® and Medicare guidelines. It details the coding distinctions for closed, percutaneous, and open treatment of fractures, clarifies how casting, splinting, and strapping services are treated within the global surgical package, and addresses the correct use of selected modifiers and radiology and supply codes. The […]
Coding Guide – Advanced Primary Care Management
Care management services have played an increasing role patient care management. CMS and other payers no longer pay only for face-to-face services, a concept that would have been unthinkable 15 years ago. CMS began paying for Transitional Care Management Services in 2013, for chronic care management services in 2014. In the 2016 Final Rule, CMS […]
Physician Fee Schedule Final Rule for Calendar Year 2026
2026 conversion factor $33.4009 ($33.5675 for qualifying APM participants) – updated 11/4/2025 Payment policies in the 2026 Physician Fee Schedule Conversion Factor For the first time, there are two conversion factors for services paid under the Physician Fee Schedule. This is a result of a law passed in 2015. The Medicare Access and CHIP Re-authorization […]
E/M Office Visit Scenarios
It can be difficult to translate the E/M rules into patient scenarios that ring true and are applicable to every day clinical encounters. The guidelines seem great in theory, but how does a clinician, coder, or auditor apply them to select the correct level of service? Here are examples based on MDM, not time, that […]
Non-Physician Practitioners in Nursing Facilities
Question: Can a Non-Physician Practitioner (NPP) see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do wellness visits in a nursing facility? Answer: Yes, NPPs may care for patients in a nursing home. These can either be billed directly by the NPP, under their own […]
Incident To Services – Medicare
Medicare has specific rules for billing for nurse practitioners and physician assistants and other office staff incident to a physician services in an office. This article includes: Description, explanation and codes for incident-to services Billing and coding rules Brief video overview Enrollment of non-physician practitioners (NPPs) for incident-to billing Pharmacists and Part B Medicare reimbursements […]
When to Use Time to Select an E/M Service
Selecting a code for an E/M service can be based on time or medical decision making (MDM) (except ED visits which must be selected based on MDM) Time includes all time spent by the billing practitioner on the date of service, not just face-to-face time, and counseling does not need to dominate the visit, as […]
HCPCS Codes for Behavioral Health
Post-discharge Telephonic Follow-up Contacts Intervention | G0544 Digital Mental Health Treatment | G0552, G0553, G0554 Safety Planning Interventions | G0560 Post-discharge Telephonic Follow-up Contacts Intervention HCPCS code: G0544 Descriptor: “Post discharge telephonic follow-up contacts performed in conjunction with a discharge from the emergency department for behavioral health or other crisis encounter, 4 calls per calendar […]
Interactive Complexity | CPT® 90785
Code 90785 is an add-on code for interactive complexity and may be added on to the diagnostic psychiatric evaluation (90791, 90792), psychotherapy services (90833—90838), and group psychotherapy (90853). It may not be reported with an E/M service, if no psychotherapy is performed on that day, or with psychotherapy for crisis, (90839, 90840). +90785 Interactive complexity […]
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