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 […]
Articles
Spotlight on up-to-date coding
Billing Admission and Subsequent Visits for Patient Having Surgery
What if I admit a patient and don’t take the patient immediately to surgery? Can I bill for the admission and subsequent visits if the patient goes to surgery later in the week? In this case it depends on when you admit the patient and when you decide to take the patient to surgery. A […]
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 […]
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 […]
Surgical Modifiers
This article includes: Surgical modifiers with definitions Guidelines for billing multiple surgical procedures Modifiers in the post-op period Avoiding CPT® modifier mishaps Citations Members can also download the Global Surgery Coding Guide. Some of the information in this article and in the billing guide is the same. Billing for Surgical Services Before submitting a claim […]
Critical Care for General Surgery and Trauma Surgeons
Critical care provided as a stand alone service is based on the seriousness of the patient, the types of interventions, and time. 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 care, with the […]
Non Face-to-Face Prolonged Service – 99358
This article covers: CPT® Rules for Prolonged Care Non Face to Face Using 99358 for phone calls Are Start and Stop Times Required for Non Face-to-Face Prolonged Care Services? There are two time-based CPT codes for non-face-to-face prolonged care services. These codes may not be used on the day of an Evaluation and Management (E/M) […]
Pecked By a Parrot. Oh No, Not Again!
When we first implemented ICD-10, we all had a lot of fun with the ICD-10-CM external cause codes. But, do we need to use them? The answer to that is no according to the official guidelines and yes if your payers require them. Here is what the official ICD-10-CM guidelines say, “There is no national […]
No Chart Left Behind: Deadline to Complete Medical Records
Years ago, I worked with a physician who was chronically behind in dictating his notes. The charts were crammed into boxes by date, lining the walls of his office. Sometimes, they flowed over into the hallway or into the break room. This caused major inconveniences when a patient called for a lab result or returned […]
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