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…
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…