Coding & Documentation

To ensure a successful ICD-10 transition at your medical practice, follow these seven steps from Rose Dunn of First Class Solutions, Inc

Medical coding guidance on Medicare Annual Wellness Visits; RVU reductions; physician scribes; student documentation; and more.

Even with a one-year delay to implement ICD-10, healthcare organizations are concerned about the magnitude of the change, and are warning providers that they still need to start preparing sooner than later.

Coding questions? We've got the answers.

Despite a delay in implementation, Dan Howard of Cook County Hospital explains his facility's transition to the new coding standard.

Coding questions? We've got the answers

Compare your E&M coding patterns with national norms from Medicare. It's a fast way to see if you are out of whack. Translate Medicare's data for your specialty into percentiles for easier comparison.

Here's how your medical practice should build a plan for the looming transition from ICD-9 to ICD-10 in 2014.

Coding questions? We've got the answers

QDC codes themselves carry no payment for a claim. However, using the codes correctly may result in a bonus payment from Medicare, and not reporting them successfully will result in a penalty.

Coding questions? We've got the answers

I'm curious who really benefits from the upcoming medical coding transition from ICD-9 to ICD-10.

Coding questions? We've got the answers

Coding questions? We've got the answers

What is currently the biggest obstacle for your practice in preparing for the ICD-10 transition?

Coding answers from our September 2011 journal.

With so much else changing in healthcare, it's understandable that you'd want to avoid thinking about transitioning to the coming ICD-10 code set. But the longer you wait to start, the tougher it will be to make the switch, and the more likely you are to lose money. Here's what you need to know to avoid claims denials and ensure a smooth conversion.

Here's a quick video to get you started with conducting Medicare's Annual Wellness Visit at your medical practice.

Learn when and what CPT codes to use with prolonged services codes 99354 and 99355 at your medical practice.

Coding questions? We've got the answers

This pediatric cardiologist thinks that all his patient visits should be coded as level 5s. Is he right?

This administrator wonders if his physician needs to be physically present in order to bill a 99212 for infertility blood work.

I have a physician who saw a patient for a preventive visit and also charged a 99215 for this patient on the same date of service. He used the same documentation for both visits. Should he have documented each service separately?

Questions pertaining to the new Medicare Annual Wellness Visit.

Here's some guidance on using the new Medicare G0438 and G0439 codes.

Level 5 codes based on "breadth of management" need to clearly explain "why" the reported illnesses pose significant risk to patients. Should the physician add a statement to to her assessment that explains why the combination of multiple chronic illnesses pose a risk to the patient's morbidity/mortality?

A discussion arose between the auditors in my office regarding "double dipping" and I am wondering if you would mind clarifying something for us. One auditor says that it is permissible to obtain a review of systems (ROS) from the CC of "arm pain" - using arm as the location in the HPI and pain as the ROS under MS. I have never audited in this manner and would appreciate any advice or direction you can offer.

This doc wonders if he can mix and match body areas and organ systems for an expanded problem-focused exam.

When counting points for the data reviewed in E&M, do you count "independent review of image, tracing, or specimen" (two points), for example, when a cardiologist sees a patient, interprets an EKG, and provides an E&M service?

I know that there are going to be significantly more codes with ICD-10, but will the rules change regarding how codes are assigned?