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CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

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Search Results for: document

Webinar_slides_medical record documentation

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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...]

Certificate_Medical record documentation_2022

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E/M Medical Record Documentation | Webinar

Single user access to this on-demand webinar - $159 Includes downloadable reference materials for this webinar This is not a membership and does … [Read more...]

Medical Record Documentation | Webinar

Medical Record Documentation: CMS reducing the burden Recorded April 23, 2020 CMS wants to ease the burden of physician documentation of E/M … [Read more...]

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 … [Read more...]

CMS update E/M documentation | Medical record documentation

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CMS update E/M documentation | Reducing redundancy

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CMS update E/M documentation | OIG EHR

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Email Sign up – Definitive Guide to Documenting Time

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Exam and time in a visit | Documentation requirements in E/M services

Question: For an established patient, if I don’t document a physical exam, am I required to say that the visit was a counseling visit and document … [Read more...]

Reference Sheet_Definitive Guide to Documenting Time

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Exam | Documentation Guidelines for E/M Services

This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in 2021. Continue to use the 1995/1997 … [Read more...]

Are changes coming to the E/M documentation guidelines?

Do you remember that CMS is talking about changing the documentation requirements for E/M services?  If it slipped your mind in the course of your … [Read more...]

History | Documentation Guidelines for E/M Services

This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in 2021. Definition History is … [Read more...]

Psychotherapy Documentation Guidelines | Time

Question: Is it okay to use the time description in the order as the documentation of the psychotherapy time?  The therapist selects 90832, … [Read more...]

Documenting Exam | Evaluation and Management Services

Lunch and Learn Exam is the second key component of evaluation and management services. This short video discusses the requirements for documenting … [Read more...]

Documenting History | Evaluation and Management Services

Lunch and Learn What does a clinician need to document in the history? Is it okay to say, "non-contributory"? What if the medical assistant takes … [Read more...]

Meatloaf says, “2 out of 3 ain’t bad” | E/M Documentation Guidelines

Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining … [Read more...]

Documenting time for moderate sedation of 15 minutes

Question: When my doctor personally performs moderate sedation of 15 minutes, does he/she need to document the time in the … [Read more...]

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Wondering about the rules for HCC coding?

Wondering what the rules are for HCC coding, and where you can find them? This video answers your questions. The topic is important to medical practices because risk-adjusted diagnosis coding is part of Medicare Advantage contracts, many commercial contracts and Accountable Care Organizations (ACOs). Sign up for our monthly newsletter to download the whitepaper and watch the video.

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Latest Intel

Diagnosis Coding for Antepartum Care

Question: Patient seen for antepartum care but … Read More...

2023 CPT E/M Changes

Ready to learn about the 2023 CPT® E/M changes? … Read More...

Outpatient Diabetes Self-Management Training (DSMT) Services

Diabetes self-management training (DSMT) services … Read More...

2023 CMS Proposed Physician Rule | Webinar

CMS’s 2023 Proposed Physician Rule August 25, … Read More...

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

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. For more about Betsy visit www.betsynicoletti.com.

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