Tag: Coding Documentation

Medical Coding Regulation Guidelines

Compliance Compass: Guiding You Through Medical Coding Regulations

Coding regulations are a complex and ever-changing landscape. It can be difficult to keep up with the latest changes, and even more difficult to ensure that your coding is compliant. That’s where the Compliance Compass comes in. The Compliance Compass is a comprehensive guide to coding regulations. It covers everything from the basics of coding […]
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Using-Modifier–25-on-an-EM-Visit

Using Modifier – 25 on an E/M Visit

In recent years, there has been an increase in scrutiny regarding the use of modifier -25 to identify separate evaluation and management (E/M) services on the same day as another procedure. Insurers are now demanding documentation of such services both before and after payment, leading to a significant administrative burden for urology practices. The reason […]
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Important-Changes-to-ICD-10-CM-Codes-and-Guidelines

Important Changes to ICD-10-CM Codes and Guidelines

New codes and updates become effective April 1. The updates to ICD-10-CM and ICD-10-PCS that become effective April 1 were released in mid-January. The updates include 42 new diagnosis codes. The significant changes to the ICD-10-CM guidelines are the following: A.19 – Code Assignment and Clinical Criteria This section has added a new sentence: “If […]
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Common-Coding-Mistakes-Physicians-Make

Six Common Medical Coding Mistakes Physicians Make

Not Coding the Highest Level When it comes to ICD-10 coding, a coder’s job is to code to the highest level of specificity. This means detailing and abstracting the most information out of the medical reports from the provider and taking accurate notes. It also means knowing the medical terminology for both procedures and diagnoses. […]
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How-To-Improve-And-Make-EHR-More-End-User-Friendly

How To Improve The EHR And Make It More End-User-Friendly

Erica Remer, MD, CCDS, a Member Board of Directors of American College of Physician Advisors, have been talking about improving the electronic medical record and making it more end-user-friendly. Today, she grouses about documentation in general. Her husband, who is a radiologist, and she were commiserating at how awful and uninformative provider documentation has become […]
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Electronic-Medical-Records-Are-Not-Infancy

Electronic Medical Records Are No Longer In Their Infancy

It’s a New Year, and welcome, 2023! When I still practiced clinically, I once got a job as an emergency physician at a brand-new hospital. I was really excited, because I recognized the opportunity for our department to develop our own best-practice culture. I was hoping the staff would gel in an environment of cooperation, […]
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Medical-Coding-Audits-Trends-and-Guide

Medical Coding Audits: Trends and Guide for Physicians

You’ve received a request for medical records from a payer, who is going to conduct an audit on your claims. Your Electronic Health Record (EHR) system is excellent, the notes are voluminous, your providers are well-versed at coding. If anything, you under code! You provide excellent care for your patients and achieve great outcomes. No […]
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How-to-Avoid-Medical-Board-Complaints

How to Deal, Avoid, and Solve a Medical Board Complaint

Most physicians spend their sleepless nights worrying about malpractice lawsuits but not medical board complaints. However, a complaint to a medical board is a considerable challenge posing as much risk to a physician’s career as a malpractice case. Such a complaint often can be very trying and potentially damaging to one’s reputation. Some of the […]
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CPT®-and-HCPCS-Newly-Added-and-Revised-Codes

CPT® and HCPCS Newly Added and Revised Codes

CPT® codes are effective Jan. 1, 2023. The American Medical Association (AMA) released CPT 2023 on Sept. 12. There are 225 new codes, 75 deletions, and 93 revisions. Most of the changes fall in the Evaluation and Management (E&M) section. The 2023 CPT codes are effective Jan. 1, 2023. The October 2022 release of the […]
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