If It Isn’t Documented, Did It Really Happen?

June 7, 2024   |   By: Bridget Smudrick, BS, MLS(ASCP)  |  Director of CLIA Compliance Where CLIA compliance is concerned, documentation is key. CLIA stands for the Clinical Laboratory Improvement Amendment. This set of federal regulations established in 1988 governs how patient testing is performed in the clinical laboratory setting. These regulations ensure the accuracy of…

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Navigating E/M Reporting: Time-Based Billing and Separately Reported Services

March 29, 2024 | By: Teresa Schrage, RDCS, RVT, CPC, CPMA Reporting an E/M with separately reported services continues to be a topic of discussion amongst coders, auditors, and providers. First, let’s review what a significant, separately reported E/M is and what identifies the service. An E/M is significant and separately identifiable from a procedure/service…

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Understanding Eye Allergies

April 12, 2024   |   By: Tammy Welch, CPMA Eye allergy, also called allergic conjunctivitis, is quite common. They occur when the eyes react to something that irritates them (called an allergen). The eyes produce a substance called histamine to fight off the allergen. As a result, the eyelids, conjunctivitis, and eye allergies do not spread…

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Supervision of Ancillary Staff

April 26, 2024 | Sean M. Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC  The perennial inquiry into the scope of services that nurses and ancillary support staff may offer under physician supervision remains a frequent topic of discussion. Furthermore, I frequently encounter situations where the concept of “incident-to” care is central to the controversy.…

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