December 17, 2021 | By Stephanie Moore, CPC, CPMA Many facilities will require a preoperative history and physical within 30 days of a procedure. Does this requirement from the facility support the medical necessity of an E/M visit? The answer is maybe. Medicare transmittal 1719 states, ”For purposes of billing under the Physician Fee…
November 26, 2021 | By Toni Elhoms, CCS, CPC, CPMA, CRC As I am sure many of my colleagues can relate, I have frequently heard statements like, “All my E/M services are coded based on time because it’s just easier” or “I add total time to all my notes just to cover my bases”.…
October 22, 2021 | By Scott Kraft, Auditing Specialist, DoctorsManagement Like many of my auditing colleagues, I entered 2021 with a solid understanding of the rules of the 2021 E/M Documentation Guidelines, but looked forward to seeing how they were applied in practice by the rendering provider. Now that we’ve entered October, one area…
September 28, 2021 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT The mechanics of auditing can, of course, be acquired through a training course; but then when you find yourself in certain audit roles, you may recognize the lack of experience within skills briefly mentioned during that training. So, how do you work…
October 12, 2021 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT 2021 AMA guidance indicates that a general systemic symptom such as fever should not be considered a systemic system, but not all fevers fall in this category. The question typically posed is: what is the “magic” range that identifies it as no…