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September 16, 2025

Moderate or High MDM – General Surgery

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 […]

Coding Guide – Global Surgery

This guide from CodingIntel explains surgery coding guidelines and the global period for procedures, and includes the contents of our original CPT® and HCPCS Modifier Guide.

Coding Guide – Newborn and Pediatrics

Neonatologists, pediatricians and family physicians who care for newborns and sick children in the hospital need to select the category of code that describes the condition of the patient. There are distinct categories of codes to describe each of these situations. There are also codes that describe services to patients who are in the process of being transferred to a higher acuity facility. This guide describes the codes to use in each situation.

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 […]

Quick Coding Reference Sheet – General Surgery

This quick reference sheet is packed with useful information. It covers consults, initial and subsequent hospital visits, and observation.  Specifically for general surgery, it includes: CPT® codes for each of the above categories, documentation requirements, MDM examples, and more…

Excision of Soft Tissue, Lipoma Removal

This chart is a quick reference for soft tissue excision. It includes anatomic location and size for subcutaneous and subfacial excisions.

How Physician Services are Paid – Infographic

CPT® codes, HCPCS, modifiers, global surgical packages, CMS formulas, diagnosis codes, location, and more…how do all these pieces come together for medical reimbursement? This helpful infographic from CodingIntel shows how physician services are paid with proper medical billing and 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 […]

Definitive Guide to Documenting Time

Office visits, inpatient care, prolonged services, critical care…properly documenting time can help ensure that you receive the maximum allowable payment for the time you spent with the patient. Use this handy reference guide to make sure your documentation includes all the necessary components.

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

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) service, such as an office visit or hospital service.  Physicians and other qualified health care professionals who have E/M in their scope of practice may use these codes.  CMS […]

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

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