In the ICD-10-CM guidelines, there is an entry for only history codes at I.C.21.c.4, and there are two types of history Z codes: personal and family. History codes can be used on any medical encounter regardless of the reason for the visit. A history of an illness may alter what treatment is ordered for a patient, so it is important information to report. This directly supports the medical necessity of the encounter, which is the overarching criteria to report the outpatient or office visit...

Care Management services are being reported at an all-time high but they are not all alike. Before submitting claims, many providers have not read the directions — or CPT-published guidance and criteria. Terry breaks down the confusion and discusses why this is more of a value-based service than a monetary windfall. Listen to this informative episode for more details. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

After all of the CMS continued updates for Telehealth, we finally got an update from the AMA, that was added to CPT 2024. This gives us the “criteria” on how a service can be CPT considered for Telehealth inclusion. Terry shares this insight, plus her commentary on how to implement it into your updated compliance programs. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

Leveling an E/M visit can be considered very subjective. Clinicians and auditors alike can come to one conclusion or another. It is important that when you take online advice, you also consider “best practices” and payer-published guidance before you do only the minimum (or what is “technically” correct). Terry makes this clear distinction in today’s CodeCast Podcast. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

The 2024 Medicare Final Rule was published on November 2nd, and the Split/Shared visit guidance will parallel the CPT guidance. However, CMS will still expect the -FS modifier from the billing provider. Terry breaks down the rules in this episode to ensure misinterpretations do not have providers reporting incorrectly. Also, Terry takes a look at abdominal aortic coding. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

Join us for a great Halloween episode as Terry provides the top ten spookiest ICD-10-CM codes. She also discusses preventative and OV on the same date. And what happens when a Telehealth video visit loses feed? Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google Podcasts – https://play.google.com/music/listen#/ps/Ia47t6quqphhsanlzpajk37yiga * Spotify...

CMS recently updated their published guidance, MLN909160 July 2023, with further examples and instructions on how to gather information and documentation when a CERT Audit issues a request for an ADR (Additional Documentation Request). You don’t want to ignore this, but embrace the process and understand that this oversight helps everyone. Terry breaks it down. Also, some insights on Telehospital expansions assisting rural communities. Subscribe and Listen You can subscribe to our...

Clinical Documentation Integrity, or CID, is important. Outdated information, or information that doesn’t make sense for that date of service encounter, brings into question the reliability of the entire patient record. Have you updated the language to fit with the current times? Terry shares a few examples of issues that can raise red flags during an audit. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

The 2024 CPT codes have been released. Terry briefly looks at the additions, revisions, and deletions and what the E/M code descriptors are revising. Terry will also offer her last clarification into MNT coding since there continues to be a push to report these codes when the diagnosis is not covered. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google...

The CPT definition of a significant, separately identifiable service relies on determining the correct level of E/M service to be reported. Terry discusses what questions should be asked before you determine whether an E/M service justifies the use of modifier 25 according to CPT guidelines, CMS rules, and payer policy language. Also, this episode’s coding question is a reminder of how to use the TCM rules. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

Physicians are educated and trained more extensively than any other healthcare professional. A misrepresentation of a practitioner’s level of licensing, i.e., using the clinical term “doctor” when there is no MD or DO behind the term, is not only misleading but can jeopardize patient safety, expectations and outcomes. Terry dives into this controversial topic, stating where the blurred lines are and the importance of staying in our respective lanes. Also, this episode’s coding question...

Prior authorization in health care is a requirement that a healthcare provider gets approval from an insurance plan before prescribing their patient medication or doing a medical procedure. Insurance providers use prior authorization to make sure that a specific medical service is needed and worth the cost, and that no duplicative services are being performed. Payers use prior authorization as a way to keep healthcare costs in check. Terry discusses the Medicare, Medicare Advantage, and...

The AMA MDM directions when leveling an E/M (Evaluation and Management) code (also known as office and/or hospital visits) are still confusing many providers, coders and auditors. In this week’s CodeCast podcast, Terry attempts to bring some clarity into the Data Points discussion, regarding independent interpretations versus reviewed note. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

In 2024, there will be a new add-on code for Medicare. This is a complexity code for specific long-term patients, where the provider is taking the treatment journey with the patient, in a longitudinal way. Terry goes over what the Federal Register proposal is, and who cannot consider this code in 2024. There is a lot to unwrap here. Terry also covers a bonus payer announcement that will impact many contracts. Tune in for these important details! Subscribe and Listen You can subscribe to...

In this week’s CodeCast podcast, Terry discusses the top ten coding, billing, and compliance questions from the last month. In this information-filled episode, she covers coding for staff prolonged services codes, how a physician order must be documented, what constitutes critical care coding, and more. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google...

Providers sometimes waive patients’ cost‐sharing amounts (e.g., copays or deductibles) as an accommodation to the patient. However, doing so may violate fraud and abuse laws and/or payor contracts. From a payor’s perspective, waiving cost‐sharing amounts creates two problems. First, payors often contract with providers to pay based in part on the provider’s usual charges. The OIG has argued that a provider who routinely waives copays is misrepresenting its actual charges. Second, payors...

Medicare has been making some under-the-radar updates that provider practices need to know. You could be seeing ineligible patients, with no current ID card, coming in for services. You could also see denials if you’re not careful. Terry updates some of the latest postings by CMS so that we are all on top of the information flow. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

A question that Terry often fields is one regarding billing for pre-op visits. Should these visits be billing? There is conflicting published guidance on this question from different sources. Terry discusses the difference between pre-op visits and pre-op clearances. Is it a visit performed by the surgeon or the surgeon’s QHP? Or a provider not involved with the surgery? These questions are answered in this week’s episode of the CodeCast podcast. Subscribe and Listen You can subscribe to...

When a dietician or nutritionist sees a patient, their services may not covered for bariatric patients aka obesity. It is a nice option to have, but patients, would most likely, have to pay for it themselves. Medicare is clear that they will pay for an obesity screening, and two behavioral health visits, if qualified, but the MNT (Medical Nutritional Therapy) is only for CKD (Chronic Kidney Diseased) or Diabetic patients. Listen to this episode of the CodeCast podcast for more details on...

Social Determinates of Health are important secondary diagnoses to help explain a patient’s circumstances when it comes to access to medical care, adherence to medical advice, and environmental factors that could hinder care. However, many practices are reporting these codes without a direct relationship to the problems addressed in the encounter. This week Terry discusses the dangers of miscoding and how this could be not only a PR nightmare if you get it wrong, but a legal issue if you...

CMS has not addressed a template for audio-only Telehealth visits. Therefore, Terry offers some best practices for audio-only documentation in order to stand up to and be compliant with payer audits. Terry will also talks about when E/M services are partially complete: is there anything to bill? Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google Podcasts –...

Terry revisits the rule on reporting specificity in the laterality of a diagnosis, when the physician or QHP only gives us unspecified. What can we do as coders? As a bonus, Terry also updates us on the latest “No Surprises Act” protections. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google Podcasts –...

QHPs are often certified and must be licensed. Trying to use clinicians that cannot “independently report services to payers” as QHPs will not only flag you for an audit, but you could find yourself in hot water for false billing practices. Terry offers clear guidelines to steer clear of these issues on this episode of the CodeCast podcast. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...

On an abbreviated edition of the CodeCast, it’s “out with the old and in with the new” as Terry gives some quick tips on updating your outdated EMR template relating to E/M 2023 coding. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Google Podcasts – https://play.google.com/music/listen#/ps/Ia47t6quqphhsanlzpajk37yiga * Spotify...

This week on the CodeCast podcast, Terry discusses external audits, and what you should be looking for when moving from internal to external audits. What are your objectives? Are they SMEs for your practice? What is the scope you need? It’s time to get some piece of mind in your coding, billing and compliance processes. This episode will make sure you are prepared. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts –...