Scoring elements can be challenging with the new E/M guidelines for 2021. We hope this series of frequently asked questions helps provide some … [Read more...]
Everyday Coding Q&A
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You have questions, we have answers. We will be taking the questions we receive from you and posting answers on a monthly basis. Do you have a question whose answer would benefit fellow physicians, coders, or staff as well as yourself? Send it to info@codingintel.com.
Social determinants of health
Question: I see that the new E/M guidelines for codes 99202—99215 include social determinants of health, as moderate complexity. What is a social … [Read more...]
Why and when to use Modifier CS
Question: Why and when should we use modifier CS? Answer: Use modifier CS on visits related to testing for COVID-19. Modifier CS: cost … [Read more...]
APRN and PA students and medical record documentation
Question We have students from a nurse practitioner program rotate through our practice. Can we use their notes the same way as medical student … [Read more...]
Can we give a flu shot if the doctor isn’t in the office?
Question: Do we need to have a physician in the office when our clinical staff gives flu shots? Answer: No. CMS allows flu shots to be given … [Read more...]
Non-physician practitioners in nursing facilities
Question: Can a physician assistant see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do … [Read more...]
What are the requirements for billing a TCM visit?
Question: In order to bill a TCM visit, is anything else needed besides the phone call and E/M visit? (Codes 99495 and 99496) Answer: Yes, … [Read more...]
Can we bill an E/M service with a scheduled endoscopy?
Question: Can we charge an E/M service when we do a scheduled endoscopy to account for the cost of nursing staff, supplies, pre- and post- care of … [Read more...]
New E/M rules effective date and payer policies
Question: When can we start using the new E/M rules for new and established patient visits? And, are all payers going to follow … [Read more...]
Re-admission to nursing facility
Question: If a patient is re-admitted to a nursing facility after an inpatient stay, should we bill an initial nursing facility visit or a … [Read more...]
Counting conditions in the HPI and assessment
Question: This question pertains to the 1995/1997 Guidelines, and not to the revised office/outpatient codes 99202--99215 in 2021. When … [Read more...]
Transferring a sick baby to another hospital
Question: Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who … [Read more...]
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 … [Read more...]
What is an interval history?
Question: What does it mean when it says a code requires an “interval” history? Answer: It is a history that does not require past medical, … [Read more...]
Initial hospital service codes and established patients
Question: We are having a disagreement in our coding department. Our cardiologist sees an inpatient at the hospital, but it’s a patient she knows … [Read more...]
ROS requirements for preventive services OB/GYN
Question: What are the review of system requirements when an annual physical (99381-99387, 99391-99397) is performed/billed by an OBGYN … [Read more...]
Anticoagulation management | Can we bill for RN services?
Question: My question is regarding Anticoagulation Management Code 93793. Guidelines state that this code can be performed by a physician, NP, or … [Read more...]
Diagnosis coding for biopsy sent for pathology
Question: What diagnosis code should you use when sending a skin biopsy to pathology? a) D48.5 Neoplasm of uncertain behavior of skin, or b) … [Read more...]
Incident to and change to medications
Question: A CodingIntel member writes: "I am getting mixed information about incident-to and I was wondering if you could weigh in? If a NPP … [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...]