CPT® has added 99491 to the section of chronic care management codes. The other code in this section is 99490 and there are two codes in the complex … [Read more...]
Search Results for: medical decision making
Pre-operative Clearance in Primary Care
Primary care practices are frequently asked to do preoperative evaluations or clearances on their own patients by a surgeon. Although a routine … [Read more...]
E/M in 2019: A Look Ahead
Now that the dust has settled from the release of the Physician Fee Schedule Final Rule, maybe it’s time for a re-cap. This article will also discuss … [Read more...]
E/M for Dermatology | History, Exam, MDM
Accurately documenting and coding E/M services is critical to reducing compliance risk and maximizing revenue for the evaluation and management … [Read more...]
Modifier 25 for Dermatology
Modifier 25 Significant, separately identifiable E /M service by the same physician on the same day of the procedure or other service Use to … [Read more...]
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...]
Smoking Cessation Coding, 99406 and 99407
Medicare and most private insurers pay for physicians, NPs and PAs to counsel patients regarding smoking cessation. Medicare waives the … [Read more...]
Emergency Department Visits
Definition Emergency department (ED) services are E/M services provided to patients in the Emergency Department. Explanation These services … [Read more...]
Exam | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
Quick Coding Reference Sheet – Home visits
This is the quick reference sheet for home visits using the 1995 1997 guidelines. As of Jan 1, 2023 these guidelines will no longer be in use. Why … [Read more...]
Lesson 2: Exam
Exam is the subject of lesson two. Learn the differences between the 1995 and the 1997 exam. Before you begin, download the lesson material When … [Read more...]
Lesson 1: History
Lesson one of E/M auditing covers medical necessity and cloning, and all things history. Hear about who can document the HPI, ROS and PFSH and what … [Read more...]
E/M Auditing in Depth
While rumors swirl about possible changes to E/M coding, coders on the ground are still reading and auditing E/M notes. This two-hour course goes into … [Read more...]
Billing for Pap Smear
Billing for pap smears in a physician practice can be confusing for clinicians. Pap smears can be screening services or diagnostic services … [Read more...]
Scoring MDM in an E/M Note
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
CPT® Code 99483: Cognitive Assessment and Care Plan Services
Developed in 2018, this service describes an in-depth assessment and development of care plan services for new or established patients who have signs … [Read more...]
Avoid These 4 Costly Errors When Coding Minor Surgical Procedures
Does your practice perform any minor or major procedures? If so, this post is for you! Primary care practices and urgent care centers should pay … [Read more...]
History | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
Reporting a Problem-Oriented Visit on the Same Day as Welcome to Medicare (G0402) or Initial and Subsequent Wellness Visit (G0438, G0439)
I continue to hear that some consultants and coders don't agree with reporting a problem oriented visit with welcome to Medicare or wellness visit … [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...]
HCPCS Code G0505: Cognitive Assessment for Patients with Dementia
In 2017, CMS developed a HCPCS code, G0505, for cognitive assessment of patients with a cognitive impairment. This code was replaced in 2018 with … [Read more...]