Question: I heard coding for prolonged services is changing in 2021. Is that true? Answer: Yes. There will be a new CPT® code for 15 minutes … [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...]
Are start and stop times required for non face-to-face services?
Question: Regarding non face-to-face prolonged care, does Medicare require start and stop times, they way they do for prolonged face-to-face care? … [Read more...]
Exam | Documentation Guidelines for E/M Services
Definition Exam is one of the three key components (history, exam and medical decision making) of Evaluation and Management Services. Read about … [Read more...]
Using Time to Select a Code
Some Evaluation and Management codes, and some other codes are defined by the amount of time of the service. When a CPT® code is defined by time, the … [Read more...]
Time based rules | Behavioral health services
Psychiatrists, psychiatric NPs and psychiatric PAs provide medication management using E/M codes and psychotherapy services. There are specific rules … [Read more...]
Not all emergency surgery should be coded at the highest level | E/M Services and MDM
Surgeons sometimes think that the E/M service on the date of every emergency surgery is the highest level E/M. 99285 or 99223. This article … [Read more...]
Code Prolonged Services with Confidence | Webinar
Recorded April 10, 2018 Few services are as confusing or as rewarding as prolonged care codes. In 2018, CMS added two new HCPCS prolonged services … [Read more...]
Medical necessity isn’t medical decision making
Have you heard of Talk Ten Tuesdays? It’s an internet radio program hosted by Chuck Buck and Dr. Erica Remer, and every week they discuss current … [Read more...]
Scoring MDM in an E/M Note
Question: I have a question about scoring MDM in an E/M note. One of our coders thinks that if there is a new problem with labs ordered (new … [Read more...]
Let’s go to the source! Should this visit be downcoded?
A physician asked me this question: “As an interventionalist, a good part of my visit is spent not only explaining patients conditions to them but … [Read more...]
History | Documentation Guidelines for E/M Services
Definition History is one of the three key components (history, exam, and medical decision making) of Evaluation and Management Services. You can … [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...]
Medical Decision Making | Documentation Guidelines for E/M Services
Definition Medical decision making (MDM) is one of the three key components of evaluation and management services. (Make sure you read about the … [Read more...]
Moderate or High MDM – General Surgery
Accurately select the level of medical decision making, using the 1995 and 1997 Documentation Guidelines. This article provides examples of moderate … [Read more...]
Can I code at a higher level if everyone in the exam room is crying?
This short video addresses your questions about coding a higher level of service due to patient behavior. Includes CPT® guidelines, tips on selecting … [Read more...]
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 … [Read more...]
Non Face-to-Face Prolonged Service – 99358
Codes 99358 and 99359 are used for non-face-to-face prolonged services by the billing physician/NP/PA when provided in relation to an E/M service on … [Read more...]
Prescription drug management and medical decision making (MDM)
The Documentation Guidelines identify three key components in E/M services: history, exam and medical decision making. When should you count … [Read more...]
Your Patient Wants to Talk: How to Bill for Discussion Visits
The current CPT rules for office visits say time may be used to select a code for new or established patients if counseling/coordination of care … [Read more...]