2023 Audit Planning

How many charts have you guys already audited in 2023? That’s a really big question. I hope you’re already starting to discuss your audit plan for 2023. It’s not too early, and I hope you’ve already started actually auditing charts for 2023. I recently sent out an audit tip that addressed productivity and quality production…

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HIPAA Considerations When Business Associates and Data are International.

  December 9, 2022 | By Rachel Rose, JD, MBA Overview Although it is said that “business is global”, there are some nuances to this blanket statement to consider when creating, receiving, maintaining, or transmitting electronic protected health information or electronic health information (herein the blanket term “PHI” is used) internationally.[i] Before delving into items…

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The Role of the History and Examination in 2023 Evaluation and Management Services

  December 2, 2022 | By Jill Young, CPC, CEDC, CIMC While listening to the virtual AMA CPT/RBRVS Annual Symposium lecture by Gift Tee, BS, MPH, Director of the Division of Practitioner Services in the Hospital and Ambulatory Policy Group (HAPG) of CMS on the Update from Centers for Medicare and Medicaid Services (CMS), I…

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A Long Time Coming: 2023 Changes to Inpatient Prolonged Services

  November 25, 2022 | By Grant Huang, CPMA, CPC It’s been two years since CMS collaborated with the AMA to revamp Evaluation & Management (E&M) coding guidelines, including a rework of prolonged services codes in the office/outpatient setting. This process culminated in a disagreement between the AMA’s CPT manual and CMS’ fee schedule final…

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Incident to isn’t just about E/M services

  Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.…

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