When a patient presents for an injury after a fall, practitioners may be tempted to search for the word “fall” and select the first diagnosis that they find. Perhaps, they find the code W06.xxxA “fall from a bed” or even W19.xxxA “unspecified fall”. They select the code, close the encounter, and move on to the […]
HCPCS code G2211
Table of Contents G2211 FAQ Changes to G2211 in 2025 and 2026 Not all visits Clinician’s relationship with the patient, type of problem Acute condition, seen in primary care CMS expected frequency Q&A from CodingIntel’s August 17, 2023, CMS Proposed Rule Webinar G2211 Visit complexity inherent to evaluation and management associated with medical care services […]
“xxxA” – ICD-10-CM Placeholder Code X and 7th Character Extension
When I was reviewing terms people use to find CodingIntel I was surprised to find that people were searching for “xxxA.” At first, I was afraid searchers were looking for a different kind of site….or sight. I hope some searchers were looking for information about placeholder code X and 7th character extension A. These are […]
Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!)
Question: In 2026, how will we indicate practitioners are providing longitudinal or complex care who are in assisted living or receiving services in their home? Answer: In 2023, the codes for services performed in a patient’s home or in an assisted living facility were combined to one code set. Codes (99341—99345 for new patients) and (99347—99350 […]
Acute, Uncomplicated vs. Acute with Systemic Symptoms
Question: When using the E/M guidelines, is the problem an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!) Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity […]
Billing for Pap Smear
Billing for pap smears in a physician practice can be confusing for clinicians and coders alike. Pap smears can be screening services or diagnostic services There is a HCPCS code for obtaining a screening pap smear, Q0091 Performing a pelvic exam is either part of a preventive medicine service or problem oriented visit CPT® add-on […]
Risk: Roads not Taken
How is risk assessed when selecting a level of E/M service? We know that the risk of additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used to select a level of E/M. But, how about the risk of the condition itself? This short […]
What is the Risk of a Referral?
Question: What level of risk is assigned when a practitioner refers a patient to a physician in another specialty? Does the complexity of the problem (eg, melanoma) make a difference? Answer: Watch this brief video for the answer. You can also download the slides here.
OIG Report on Telehealth During the PHE
What? An OIG report without doom and gloom? Fire and brimstone? Slides In February, 2024 the OIG released an audit report of telehealth E/M services performed between March 2020 and November 2020. During this nine-month period practitioners submitted claims for 19 million E/M services. Before I talk about the report though, let me congratulate everyone […]
2026 RVU Table
Looking for 2026 total RVUs? Or work RVUs? This year, and in coming years, there are two conversion rates, so we haven’t done the fee calculation. For practitioners who are Qualified Professionals in a Medicare Shared Savings plan, the conversion factor is $33.57. For non-QP Professionals, the conversion factor is $33.40. If you want to […]
HCC Coding: V24 to V28
The transition from V24 to V28 of the HCC model is almost in the rear view mirror. For most groups with risk contracts, this really is old news. We’ve left the video for another year for anyone who needs to catch up on the overview of the change. CMS pays Medicare Advantage (MA) plans using […]
Age and Wellness Visits | Eligibility for Welcome to Medicare
Who can perform the AWV Knowing which Medicare wellness visit to bill Eligibility requirements for the Welcome to Medicare visit AWV and chronic care management A few years ago, I gave an AWV presentation at a family medicine conference and afterwards a physician said to me, “What you just told me will pay for the […]
Facility versus Non-Facility in the Physician Fee Schedule
Understanding facility versus non-facility in the physician fee schedule explains the total RVU and payment differences that practices receive when performing the same service in different settings. The Medicare Physician Fee Schedule has values for some CPT® codes that include both a facility and a non-facility fee. Some services may be performed in either an […]
Medicare Advantage Plan Network Issues
Question: My sister is thinking of enrolling in a Medicare Advantage plan. In our practice, we have issues with pre-authorizations and denials. I’ve warned her about network issues. Is there anything else I should tell her? Answer: I’m so glad you asked. I’ve had this conversation with my own family and friends. Medigap plans If […]
Coding Matters™
Health care coding news matters to coders, billers administrators and practitioners in medical practices. Often, there’s new beyond new codes or new policies and keeping up-to-date with that news can inform decisions that practices make. CodingIntel’s Coding Matters® page will help you be in the know about government regulation, compliance actions, third-party policies and the […]
Medicare Coverage for Marriage and Family Therapists and Mental Health Counselors
In the Consolidated Appropriations Act, 2023 Congress mandated that Medicare provide coverage and payment for the services of health professionals who are Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs). The effective date of coverage was January 1, 2024. And of course, these professionals must enroll in Medicare in order to provide the […]
As Time Goes By
One of the complexities for medical practices is using time in CPT® coding. CPT® has long had a unit of time rule that a unit of time is met when the midpoint has passed. That is, you’ve reached an hour after 31 minutes. There are many CPT® codes that follow this mid-point time rule including […]
Why Not Bill All 99213 Visits in an FQHC?
Practitioners who work in Rural Health Centers (RHCs) Federally Qualified Health Centers (FQHCs) can get in the habit of billing all level three office visits, understanding that for Medicare and Medicaid patients, payment is the same no matter what level of service is reported. Whether the visit was a simple visit or the patient had […]
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 preventive medicine service and addressed an acute, significant problem. The patient was new to us. Should we bill both as new patient visits? Answer: The last time I saw this addressed by CPT® […]
CMS Update on Medical Record Documentation for E/M Services
The world as we knew it Both the 1995 and 1997 evaluation and management (E/M) documentation guidelines stated that ancillary staff could record a review of systems (ROS), and past medical, family, and social history (PFSH) in a patient record. The billing physician/NP/PA needed to document that that information had been reviewed and verified. Only […]
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) D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin