Do you hope for the perfect audit review meeting? You audit an entire team of providers who either have 100% accuracy or they don’t, but they greet your feedback with grace and humility. It helps when you of direct communication and real curiosity and engagement with the medical team, but results are not guaranteed. Auditing […]
Coding vs. Clinical Validation
Understanding Distinct Roles, Responsibilities, and Qualifications in Healthcare Documentation Two critical functions are often misunderstood or conflated: medical coding and clinical validation. While both are essential to accurate documentation, appropriate reimbursement, and regulatory compliance, they are fundamentally different disciplines that require distinct skill sets, credentials, and areas of expertise. Confusing these roles—or allowing one professional […]
Cerumen Removal
There are two codes for cerumen removal 69209 Removal impacted cerumen using irrigation/lavage, unilateral 69210 Removal impacted cerumen (separate procedure), 1 or both ears Key points Document the medical necessity for cerumen removal (patient’s complaints, diminished hearing, physical exam) Document the results: was the procedure successful? Whether it is a clinical staff member or practitioner […]
Compliance Issues in ICD-10 Coding for Risk Based Contracts and HCCs
How to be a great HCC coder? Know ICD-10-CM Official Guidelines for Coding and Reporting During an encounter: Code conditions assessed and managed. If treatment of an acute or chronic problem is affected by an ongoing condition, note that, and add the ongoing condition to the claim form. If the condition has a manifestation or […]
Coding for Telehealth
In this article: Telehealth and Extended Flexibilites – Feb, 2026 Telehealth Prior to the Pandemic Current Telehealth Rules Important Details (modifiers, frequency, teaching physicians, and more) RHCs and FQHCs Place of Serivce CPT® Codes for Telehealth Is it or isn’t it a Telehealth Service Communication-Based Technology Services Telehealth Flexibilities Extended Until Dec. 31, 2027! Date […]
Coding for Observation Services
CPT® Codes for Observation Services There are two sets of codes used for both inpatient status and observation level of care. Coding for observation services no longer has a distinct set of CPT® codes as those were deleted. The “observation care code” applies to Hospital Inpatient or Observation Care Services Codes: 99221–99223 for initial inpatient […]
Can We Bill Advanced Primary Care Management (APCM) Every Month?
Question: Can we bill Advanced Primary Care Management every month for a patient we sign up, even if we don’t provide any services during that month? Answer: In my opinion, no. Although other consultants have other opinions and believe they are per member/per month codes. The CMS website doesn’t address this directly in the article here. […]
Non-Physician Practitioners in Nursing Facilities
Question: Can a Non-Physician Practitioner (NPP) see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do wellness visits in a nursing facility? Answer: Yes, NPPs may care for patients in a nursing home. These can either be billed directly by the NPP, under their own […]
Leveling a Visit for an Acute, Uncomplicated Presenting Problem
Question: What’s the accurate level of service for a patient who presents with a sore throat, has a positive strep test, and is put on antibiotics? Answer: The September 2025 CPT® Assistant posed this question and said the level of service was 99213. Let’s look at this in grid form to see why. You need […]
Does 99459 Require a Chaperone?
Question: The E/M session of the CPT® symposium this year was in question-and-answer format. One of the questions was, “Is a chaperone required to use add-on code 99459?” Answer: Their answer: no. Some consultants stated that in order to use code 99459 with an office visit, consult, or certain preventive medicine services, a chaperone was […]
Crediting Independent Interpretation
Question: Can a practitioner get credit for both ordering and interpretation of a test if documented? Can you address the change from 2023 related to this? Watch this brief video or read on for the answer. Answer: In March of 2023, CPT® issued an “Errata and Technical Corrections” which added one line to the section […]
Teaching Physician Rules – Moonlighting
Question: Resident is moonlighting in an urgent care setting. The resident is licensed but not enrolled with insurance companies. Can we follow the Teaching Physician rules for this resident and bill for services jointly performed between an attending and the resident? Answer: For Medicare, no, not based on my reading of the applicable statutes. “Moonlighting” specifically refers to […]
Visits in the Maternity Package
Question: How many visits are included in the payment for the maternity care package? Answer: The global maternity package includes approximately 13 routine antepartum visits for an uncomplicated pregnancy: monthly visits up to 28 weeks, biweekly visits to 36 weeks, and weekly visits until delivery. Fewer than four prenatal visits do not qualify for global reimbursement and […]
Advance Care Planning Q&A
Does your practice provide Advance Care Planning (ACP) services? If so, read on and watch the video below. Q: Can it be billed as a group service? A: No. It is a service to an individual beneficiary and/or their family member(s) or surrogate. Q: Does it follow the mid-point rule? Should I start to bill 99497 at 16 […]
Can I Get Paid For…Removal of Sutures or Staples
In 2023, CPT® deleted code 15850 and revised code 15851. Prior to then, these codes differentiated between suture removal by the same surgeon who performed the primary procedure and suture removal performed by a different surgeon. It also used the term “under anesthesia other than local.” In CPT Changes 2023 An Insider’s View, the AMA said that […]
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 was born premature and in respiratory distress. The baby needed to be stabilized and transferred to a level III neonatal intensive-care unit. The pediatrician spent 90 minutes from the time the […]
Behavioral Health Coding Compliance
Once again, with feeling: coding for behavioral health There are two videos on this page that describe OIG audits of behavioral health services. They are evergreen. If you’re new to the field of behavioral health coding, they are cautionary tales of what not to do. Coding for Behavioral Health Compliance lessons from the OIG It’s […]
Interprofessional Internet Consultations
CMS recognizes and pays for six codes for interprofessional consults codes 99446–99449, 99451, 99452 See also HCPCS codes developed in 2025 for behavioral interprofessional consults | G0546–G0551 These codes were updated in 2023. Codes 99446, 99447, 99448, 99449 and 99451 may now be performed by physicians and other qualified health care professionals. Because these codes […]
Behavioral Health and Telemedicine
Behavioral health via telehealth is allowed permanently, thanks to the Consolidated Appropriations Act signed in Dec. 2020 and effective January 2021. The Consolidated Appropriations Act of 2021 permanently removed geographic and originating site restrictions for behavioral health services in Medicare, allowing beneficiaries to receive mental health services from any location, including their homes, without rural-only […]
Diagnosis Coding for Intentional Self-Harm
Another discussion of codes that use placeholder xxxA (or xxx with another 7th character) One of the most searched terms on CodingIntel is xxxA. Experienced diagnosis coders recognize the placeholder digits “xxx” and the 7th character extender A. When we pulled the list of ICD-10-CM codes that have xxxA in them, some relate to self-harm […]
RHC and FQHC Update
Background Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) have specific rules related to coding for service in their clinics. Both submit claims on a UB claim form that shows a revenue code and also includes the specific HCPCS/CPT® codes that were performed. RHCs are paid an all-inclusive rate for services done on […]