Scoring MDM elements can be challenging for E/M services This post includes questions related to: Major/Minor procedure Data Elements (with … [Read more...]
Medicare “Audio-Only” Telehealth Services
CMS issued multiple waivers and two interim final rules to support health care organizations and patients during the public health emergency in spring … [Read more...]
Coding Telehealth Visits: Place of Service
Information in this article was updated July 2023, based on the 2024 Proposed Physician Fee Schedule Rule. Coding telehealth visits changes faster … [Read more...]
Behavioral Health and Telemedicine During the PHE
In this post Overview of behavioral health services via telemedicine during the PHE Overview of behavioral health services after the PHE … [Read more...]
Specimen Collection For COVID-19
CMS’s 4/30/2020 rule states that practices could bill 99211 for new or established patients during the public health emergency for COVID-19 specimen … [Read more...]
Telemedicine in RHCs and FQHCs
In April, 2020Â CMS released guidance about paying for telehealth services in Rural Health Centers (RHCs) and Federally Qualified Health Centers … [Read more...]
Telecoding for Telemedicine
Some coders were already working from home either full time or a few days a week. Many practices and health care facilities implemented remote coding … [Read more...]
Why and When to Use Modifier CS
Question: Why and when should we use modifier CS? Answer: Use modifier CS on visits related to testing for COVID-19. Modifier CS: cost … [Read more...]
Modifier CS: Cost Sharing for COVID-19 Testing and Visits Related to Testing
Effective retroactively to 3/18/20, there is no cost sharing allowed for COVID-19 testing or for the evaluation visits related to the testing … [Read more...]
Payment for Telephone Calls During the PHE: CMS Rules for Phone Calls
CMS rules for phone calls has changed during the course of the pandemic. Prior to the public health emergency these had a status indicator of … [Read more...]
Lesion Destruction Tip Sheet
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...]
Non-Physician Practitioners in Nursing Facilities
Find additional information about nursing facility services  Everyday Coding. Question: Can a physician assistant see patients in a nursing … [Read more...]
New Versus established Patient Visits
There are other articles on CodingIntel about the difference between new and established patients, and the rules haven’t changed, but that doesn’t … [Read more...]
Counting Conditions in the HPI and Assessment
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...]
Drug Therapy Requiring Intensive Monitoring for Toxicity
Question: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for … [Read more...]
What is an Interval History?
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...]
Anticoagulation Management
Currently, there are two sets of codes, three HCPCS codes and two CPT® codes. They aren’t defined exactly the same, and so take careful reading. The … [Read more...]
Initial Hospital Service Codes and Established Patients
Question: We are having a disagreement in our coding department. Our cardiologist sees an inpatient at the hospital, but it’s a patient she knows … [Read more...]
Diagnosis Coding for Biopsy Sent for Pathology
Question: What diagnosis code should you use when sending a skin biopsy to pathology? a)Â D48.5 Neoplasm of uncertain behavior of skin, or b)Â … [Read more...]
Five Urban Legends About Risk-Adjusted Diagnosis Coding
Originally published on kevinmd.com When I talk to medical practices about Hierarchical Condition Category (HCCs) and risk-adjusted diagnosis … [Read more...]