December 15, 2023 | By Stephanie Allard, CPC, CEMA, RHIT One area that keeps coming up in my conversations and education sessions is the definition and understanding, or misunderstanding, of the concept of a “problem addressed” during an encounter and how that is applied to E/M services. As treating practitioners document and as we…
November 10, 2023 | By Toni Elhoms, CCS, CPC, CPMA, CRC On countless occasions, I have heard physicians and healthcare providers balk at the notion of learning how to level their E/M services based on medical-decision-making (MDM), and some will even go as far as to say things like “I don’t have time…
April 2, 2021 | By J. Paul Spencer, CPC, COC We now collectively find ourselves one calendar quarter into the new frontier of 2021 outpatient E/M services. Since January 1, I have fielded many questions from my professional contacts regarding how best to look at the newly-engineered medical decision making (MDM) component. As might…
December 25, 2020 | By By Grant Huang, CPC, CPMA The New Year is nearly upon us and with it, implementation of the much-talked-about 2021 E/M guidelines for office/outpatient codes 99202-99215. These guidelines include completely revamping how time works for selecting code levels, which in turn has resulted in brand new rules for prolonged…
October 7, 2022 | By J. Paul Spencer, CPC, COC Early September marked my 33rd year on the administrative side of healthcare. This followed my 56th birthday in April when I officially entered the realm of “pushing 60”. Once you get to be my age, the reaction to my opinion falls into one of…
July 28, 2023 | By Jill Young, CPC, CEDC, CIMC I have been a consultant for over 20 years and have worked in the medical field for over 40 years. When I first was in a position that required me to research the rules and policies of both documentation and compliance issues, there was…
September 4, 2020 | By Brenda Edwards, CPC, CDEO, CPB, CPC-I, CEMC, CRC, CMRS, CMCS Is anybody not aware of the Evaluation and Management (E/M) changes coming in January 2021? Have you asked your administrator, managers, front office, back office, and providers if they are ready for these major changes? Anybody that touches CPT® 99202-99215…
November 20, 2020 | By Brenda Edwards, CPC, CDEO, CPB, CPC-I, CEMC, CRC, CMRS, CMCS The days of 2020 are winding down and I don’t know that any of us are going to be sad to see it go. While saying goodbye to 2020 and hello to 2021, we also say hello to the…
One of the amazing benefits of a NAMAS membership is “Ask The Expert”. For this “Take”, I’m going to share one of the questions submitted to us by a NAMAS member, Carol, about emergency room leveling related around chest pain and high complexity. So, Carol writes that the data column for most of their patients…
July 21, 2023 | By Scott Kraft, CPMA, CPC Whenever I audit charts under the 2021 E/M Documentation Guidelines, which now apply in all places of service, I like to start by reviewing the first and third columns. The first column is Number and Complexity of the Presenting Problem, and the third column is…