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…
May 12, 2023 | By Scott Kraft, CPMA, CPC The E/M Documentation Guidelines implemented in 2021 essentially place, time and medical decision making on equal footing. When visit time is documented, the service can be coded based on whichever of time and medical decision making is most favorable to the provider. This has led…
March 28, 2023 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT With the adaptation of 2021 Guidelines and the reduction in documentation requirements, many coders and auditors had thought the use of copy and paste may begin to phase out. Unfortunately, this has not been the case, primarily because many providers are still…
March 31, 2023 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CDEO, CPB, CFPC, CRC, CPEDC, CEMA President, Knowledge Tree Billing, Inc. A lot happens in March! Spring officially begins — bringing with it new growth, Spring Break, and basketball fans across the country get bracket crazy with March Madness. In all the…
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…
Tough topics and gray guidelines are what we like to cover in these “Takes,” and this one is no exception. Independent Historian did get cleared up somewhat with 2021 guidelines, but there are still some nuances there. 2021 guidelines did bring about a definition for Independent Historian. It cleared up some of that grayness that…
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…
As we begin the new year and our focused training for the 2023 E&M changes and revisions, I’d like to encourage everyone to refocus their efforts on column three of medical decision-making. The header of column three is very specific, and it’s wordy. I think sometimes we fail to notice that because we’re stuck in…
I can’t remember if I’ve recently covered this topic, so one of us (or maybe both of us) may have Deja vu today. We’re still getting inundated with questions about Problems Addressed regardless of the place or type of service, so whether I’ve already covered this topic or not, it bears addressing it again. Cheryl,…
Acute uncomplicated illness or injury requiring hospital inpatient or observation level care As 2021 documentation guidelines are moving into other types and places of service, it’s time to start taking a deep dive! I want to start by looking at some of the implementations that have changed. There were two major new adaptions in the…