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ICD-10-CM Chapter Specific Guidelines – Chapters 4–6

Section I.C of the ICD-10-CM Official Guidelines for Coding and Reporting, titled “Chapter Specific Guidelines,” contains 22 chapters. These chapters offer detailed guidance on specific codes and code ranges in the ICD-10-CM manual. This article is part of a series that will delve into each of the chapters in Section I.C to delineate coding protocols […]

ICD-10-CM Chapter Specific Guidelines – Chapters 1–3

FAQ: Scoring Elements in the E/M Guidelines

Scoring MDM elements can be challenging for E/M services This post includes questions related to: Major/Minor procedure Data Elements (with link to additional resources) General questions about the guidelines Using time (with link to additional resources) Social determinants of health Major or minor procedure? Question: I have a question about how to determine if a […]

Consent for Communication Technology-Based Services (CTBS)

Both CPT and CMS have developed codes for non-face-to-face communication-based technology services in recent years. In addition to care management services, these include interprofessional consults, remote physiologic and therapeutic monitoring, and on-line digital E/M services In the 2020 Physician Fee Schedule Final Rule, CMS clarified the type of patient consent that is required to perform […]

Remote Therapeutic Monitoring

There are six remote therapeutic monitoring codes in the general medicine section of CPT® which may be performed by physicians, PAs and NPs and other practitioners such as psychologists, LCSWs, physical therapists and occupational therapists These codes are for non-physiologic measures and the results can be uploaded digitally or reported by the patient A physician, […]

Remote Physiologic Monitoring Treatment Management Services

This is an overview of coding for Digitally Stored Data Services/Remote Physiologic Monitoring in the E/M section of the CPT book. There are more detailed articles for the individual codes on CodingIntel. Put the code in the search box to find them. Medical practices can use these devices to monitor a patient’s health metrics, assess […]

Blood Pressure Self-Measurement: Education, Training and Analysis | CPT® Codes 99473, 99474

There are two CPT® codes specifically for blood pressure self-measurement and management. The first is for patient education and calibration of a home blood pressure device The second is for reviewing data collected by the patient at home, with a report and communication back to the patient 99473 Self-measured blood pressure using a device validated […]

ICD-10-CM Conventions, Structure, and Format: Section I.B

The first step to finding the most accurate code is to confirm that you are working with the correct version of the ICD-10-CM Official Guidelines for Coding and Reporting. The correct version may be the most recent update, or – in the context of retrospective coding– it may need to be a previous version that […]

Transforming Patient Collections: Expert Insights and Strategies | Webinar

Recorded October 16th, 2024
1 CEU expires 10/30/25

Guest Presenter Elizabeth Woodcock

Gain valuable insights on how to effectively respond to industry changes and actionable steps to enhance your revenue cycle management in this engaging webinar centered around navigating the current inflection point in patient collections.

Compliance Guide

You may have heard about the “Seven Elements for an Effective Compliance Plan.” In fact, if you enter that term in a popular web browser “about 575,000” results appear within seconds. Fortunately, compliance and enforcement agencies endorse the elements and provide great examples on what to do – without having to delve much into those […]

Where Does it Say That? | Webinar

Recorded October 9th, 2024
1 CEU expires 10/30/26

Guest Presenter Pam Warren of MaineHealth

This webinar is a guide for auditors and coders looking for regulatory guidance when they are answering coding, compliance and regulatory questions from practitioners and colleagues. This presentation offers common healthcare compliance scenarios and provides the location of the associated guidance.

Developing an Audit Work Plan to Satisfy Your Compliance Program | Webinar

Recorded September 25th, 2024
1 CEU expires 9/30/25

Guest Presenter Pam Warren of MaineHealth

The OIG identifies seven elements of an effective Compliance Plan. One of them is conducting internal monitoring and auditing. This presentation will look at what to audit, how to evaluate risk, how to set up your audit process, and how to report your results.

ICD-10-CM Conventions, Structure, and Format: Section I.A

As you read this article, it will be helpful if you have the ICD-10-CM book in front of you. You can download a pdf copy here. And even if you don’t download the entire book, download the Official Guidelines instead. There are four cooperating parties to ICD-10-CM. They publish and update the official guidelines for […]

Assuring Compliance for Behavioral Health Services | Webinar

Recorded August 15th, 2024
1 CEU expires 8/30/26

Guest Presenters Cheryl Krusch and Natalie Laaman of BerryDunn

This webinar reviews essential documentation requirements and coding standards, describes common denial reasons, and provides proactive steps to mitigate risk effectively. Elevate your practice’s compliance standards and ensure proper documentation and coding for revenue integrity.

IRE Inpatient Determinations: Case Studies | Webinar

Recorded August 13th, 2024

Guest Presenter Dr. Amarin “Ty” Alexander

Independent Review Entities review inpatient records for diagnostic accuracy and DRG determinations. This case-study focused webinar will describe important ICD-10-CM Guidelines that establish the rules for these decisions.

Critical Care Services

Definition and Explanation of Critical Care Service Definition: Coding service for caring for a critically ill or injured patient Explanation: Critical care has high relative value units and payments so it’s important to know the coding rules. This article describes what can be included in the time of critical care what can’t be included, and […]

Five Novel Reimbursement Opportunities – and More to Boost Your Practice’s Payments | Webinar

Recorded: June 2024

Guest Presenter Elizabeth Woodcock

The Centers for Medicare & Medicaid Services have approved five new payment opportunities for 2024 – just the beginning of what promises to be a significant shift in the reimbursement landscape for medical practices.

Commonly Performed Procedures in Primary Care

These reference sheets for minor procedures include common CPT® codes, descriptions, current work and non-facility RVUs, and global days for quick reference. The first chart includes codes 10060-11443, the second 11600-17111, and the third 20550-54056.

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 See our Medicare Incident-to and Shared […]

Nursing Facility Visits

Definition Nursing facility visits are Evaluation and Management services provided in a skilled nursing facility or a long term nursing facility. Explanation Only a physician may perform an initial nursing facility service in a SNF. This includes admissions and re-admissions. In an NF, a non-physician practitioner (NPP) who is not employed by the NF may […]

Shared Services: CPT® and CMS Rules | Webinar

Recorded May 16th, 2024
1 CEU expires 5/30/26

Shared services are E/M services jointly performed by a physician and non-physician practitioner in a facility setting. The service is reported under the National Provider Identifier (NPI) of the practitioner who performs the substantive portion of the service. The substantive portion of the service can be determined by time or medical decision making (MDM).

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