Emergency Department and Critical Care Services are often incorrectly coded because the documentation lacks clarity. Terry discusses the elements necessary to have compliant ER documentation and also what CC services need to make sure they are supported for billing.

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Obstetric coders have likely started to report E/M visits for newly pregnant patients, but they still have a few months before they need to use the full set of new and revised codes and guidelines for maternity care services as we head into 2027.

Terry brings in some recent questions and answers to to help train your team and determine where more research or training is necessary before the full code system goes into effect Jan. 1, 2027. A contributing article in Part B news from 9/28 also was used for this episode.

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Terry discusses the specialty of Podiatry procedural coding, to include some ankle surgeries, and other complex foot surgeries. She also strongly advises not to add CPT or ICD-10-CM codes to operative reports as this now handcuffing the provider to those codes whether they are over or under coded or incorrect as this report would suggest. Listen in to get the details.

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Terry gives us scenarios that are examples of work that doesn’t amount to an E/M service or can’t be counted toward an E/M service, followed by discussion of the reason why along with similar situations where it might be appropriate to report a stand-alone E/M service or count it toward an E/M service. We have to make sure we are not caught in the FWA that is happening all over the country. Listen in this week to protect your practice.

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The post E/M Coding: What Not To Do appeared first on Terry Fletcher Consulting, Inc..

How does documentation specificity affect diabetes code assignment?

The details included in a medical record can significantly affect ICD-10-CM code assignments. Terry discusses several examples to show how documentation specificity, provider links between conditions, and medication use can influence diabetes coding.

There are certain conditions for which a cause-and-effect relationship with diabetes can be assumed under coding guidelines; however, not every condition can automatically be considered related to diabetes. When a provider specifically links a condition to diabetes, that documentation can provide crucial support for accurate code assignment.

Tune in today for some insights into the frequent, although challenging condition to code.

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CMS has made permanent the policy that allows a practitioner who furnishes Medicare telehealth services from home, even what the height of COVID is over 3 years in the past. There is also confusion is what is listed as the physician’s practice location?

Terry discusses the answer to this question, as the CCHPCA has now a specific position, and also talks about the difference between Medicare enrollment vs. POS where services are performed. Different rules apply when the practitioner or group operates virtually and has no other physical practice location, and teleradiology is subject to separate enrollment rules.

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Terry discusses the 1op 10 Coding Corner Membership questions of the quarter, including Telehealth, the reality of voice recognition transcription disclaimers and some of the new proposals from CMS slated for 2027. Tune in to get the rundown.

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The post Top 10 Tuesday Medical Coding Q and A appeared first on Terry Fletcher Consulting, Inc..

Today on the CodeCast Podcast, Terry discusses a topic that comes up in auditing conversations frequently: “that an auditor needs to specialize in a certain specialty before they can audit E/M services for that specialty.” That is not necessarily true.

I understand where that thought comes from.

It can absolutely help for an auditor to be familiar with the anatomy, medications, terminology, and common treatment plans within a specific specialty. That knowledge can make the note easier to follow. It may also help the auditor know when they need to ask a question or do additional research. But does it also create a bias?

Let’s chat about this today on the CodeCast.

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