February 18, 2022 | By Stephanie Allard, CPC, CEMA, RHIT When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must…
December 24, 2021 | By Grant Huang, CPMA, CPC The 2021 E/M guidelines’ more permissive rules for time-based coding is a potential watershed moment for physicians who want to spend less of their time documenting E/M notes. But if we interpret these changes to mean that the longstanding concept of “medical necessity” can be…
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”.…
May 14, 2021 | By Jill Young, CPC, CEDC, CIMC The time has come for you to consider the “new time” method to determine the evaluation and management (E&M) coding for your office and other outpatient services. I use the phrase “new time” to differentiate it from the “old time” concept you are accustomed…
February 12, 2021 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O A few weeks ago, NAMAS presented a webinar about 2021 time and prolonged services. The flood of participant questions made it very obvious there is still uncertainty about how to appropriately use time to select the level of office…
January 29, 2021 | By Scott Kraft, CPMA, CPC One of the big changes in the new E/M Documentation Guidelines for 2021 for office and outpatient service codes 99202-99215 is the new high-risk category of “Decision Regarding Hospitalization.” As an auditor, the first thing I thought about were the situations in which a very…
December 11, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O There is a long-standing rule in our family that Christmas is not allowed to start until the Thanksgiving dinner dishes are washed and put away. I must be completely honest; that family rule has been thrown out the window this…
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…
November 6, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O Pumpkin spiced lattes are back at Starbucks, the days are getting shorter, there is a crispness in the air (in some parts of the country, anyway), and the 2021 ICD-10-CM guidelines have gone into effect. These are all signs we…
October 23, 2020 | By Grant Huang, CPC, CPMA It’s not even 2021 yet, but gray areas have already surfaced in the 2021 E/M documentation guidelines, as more and more coders and auditors read the fine print. The 2021 guidelines, which will apply only to outpatient/office visit codes 99202-99215, are being implemented in part…