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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