Question: I believe that I know the answer to this question but am hoping you know the source, as I can't find it -- if a nurse helps with ROS, … [Read more...]
Everyday Coding Q&A
When meeting with coders and clinicians, the same issues and concerns arise year after year. We've translated those into a searchable Everyday Coding Q&A.
Diagnosis Coding for Antepartum Care
Question: Patient seen for antepartum care but delivered at 38 weeks at a different hospital/physician group. What diagnosis codes should we … [Read more...]
Acute, uncomplicated vs. acute with systemic symptoms
Question: When using the 2021 office visit guidelines, is the problem an an acute, uncomplicated illness or an acute illness with systemic … [Read more...]
Does a practitioner need to document time for a telehealth visit?
Question: Does a practitioner need to document time for a telehealth visit? What if it is audio only? Answer: First: For a telehealth visit, … [Read more...]
Coding for ultrasound guidance
Question: Can you do an article on coding ultrasound guided musculoskeletal procedures and point of care (POC) ultrasound coding and documentation … [Read more...]
Should we begin using the new CPT modifier -93
Question: Should we begin using the new CPT® modifier -93? Answer: I recommend a wait and see approach. Here’s the definition from the AMA, … [Read more...]
Can we bill a new patient visit for preventive and E/M services on the same day?
See our on-demand webinar, Preventive medicine and Medicare wellness visits with an E/M. Question: Our physician saw a patient and did a … [Read more...]
Does HCPCS code G0444 require a full 15 minutes?
Question Does HCPCS code G0444 require a full 15 minutes, or can you use it if 8 minutes are documented? Answer The reason for this question … [Read more...]
FAQ: Scoring the elements in the new E/M guidelines for 2021
Scoring elements can be challenging with the new E/M guidelines for 2021. This article is updated based on the 5/25/2021 AMA webinar, given by … [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
Find additional information about nursing facility services in Betsy's signature resource Everyday Coding. Question: Can a physician assistant … [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...]
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? This question related to the 1995/1997 Documentation … [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...]