We find ourselves halfway through 2022 and already we’re looking forward to the end of the year to see what those 2023 documentation guideline changes will be. I am most excited to see what those changes will be as we expand 2021 documentation guidelines into other types and places of E&M services and personally, I…
You know, most of the training I see out there, and even most of the training that I’m asked to do on E&M 2021 documentation guidelines surrounds MDM, so a lot of it isn’t even on time-based. So, set your watch. Let’s spend just a few minutes talking about…time. I’d like to start off by…
Have you ever had one of those questions that you think you have the answer to, but the more you read it, the more you’re swayed the other way — and then you read it again and you have an even different answer? Well, one of our NAMAS members (and a friend of mine) emailed…
I would like to make things right the first time so often, that they have errors and I need to make corrections -and the same is true for providers. In this post, I would like to approach the topic of addendums. The thing about addendums is… there are no clear-cut rules – except how to…
You know, those conversations you have between another coder and auditor or better yet, those difficult conversations with a physician about the mechanics of the code vs. the intent of the code? That’s what I want to discuss today. Sometimes this gets lost and it gets the better of us as a coder and/or auditor.…
Most of you are familiar with the medical necessity of the E&M encounter prior to 2021 documentation guidelines. But how does that equate in 2021? Today, we’re going to talk about how to understand medical necessity and 2021 documentation guidelines in the auditing of your encounters. Let’s take a look at the medical decision making…
In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding the lack of interpretation about what…