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Counseling Must Dominate Exception Claims For Seamless Payment

Choose the service level using the documented history, exam, and MDM.
Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that […]

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Set the Record Straight: ICD Code Options for COPD

What your pulmonologist writes in the documentation matters.
The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary).
Background: According to the National Heart […]

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  1. 3 Pulmonary Diagnosis Coding TipsRemember to focus on acute conditions & exacerbations. Correctly reporting…
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Get Paid for EM Visits: How Much ROS Documentation Is Enough?

Caution: Keep enough paperwork on hand to back up EHR.
Transitioning to the world of Electronic Health Records (EHR) can make your coding easier on many levels, but don’t take it for granted. Physicians often fall short in their review of systems (ROS) documentation whether you use paper charts or rely on EHR, but you can […]

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