Article Reference Code: NAMAS.07.11.2025 Understanding Coding, Documentation, and Common Pitfalls in Moderate Sedation Services Written by: Aimee Wilcox Moderate (conscious) sedation is an important component in enhancing patient comfort and cooperation during various medical and dental procedures. It is a drug-induced state during which patients remain conscious and able to respond to verbal instructions but…
Understanding New Audio-Only and Brief Telehealth E/M Codes: Documentation, Compliance, and Medicare Guidelines Written by: Gabriel Aponte Moberg The audio-only codes 98008 through 98015 require more than ten minutes of synchronous, real-time verbal communication. These services may be selected based on either total time or medical decision-making (MDM). Each code corresponds to specific MDM levels and…
Before You Bill Incident To—Is the Treatment Plan Really There? Scott Kraft, CPC, CPMA, CEMC, CPA-RA Whenever you perform an audit under Medicare’s Incident to billing rules, you’re really auditing two different things. First, did the visit note support the code assigned and whether it included any documented changes to the patient’s treatment plan. Second,…
Law vs. Health Law Fundamentals Written by: Rachel V. Rose, JD, MBA When was the last time you thought about what the “law” actually is and how it differs from what is commonly known as “health law”? Black’s Law Dictionary (2nd Ed.) provides two definitions: That which is laid down, ordained, or established. A rule…
The Auditor’s Role in Appeals: A Key Player in the Compliance Process Written by: Betty Hovey, BSHAM CCS-P CDIP CPC COC CPMA CPCD CPB CPCI The appeals process is a critical component of health care compliance, ensuring that denied claims are appropriately challenged and reconsidered. When providers and health care organizations receive claim denials, they…