In CMS
Aug 8th, 2018
During a July 18, 2018 CMS Twitter™ podcast, CMS National Coordinator for Health Information Technology, Donald Rucker, M.D. defended the new CMS 2019 proposal to make documentation of the History optional for health records. He was asked, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible ...
In Coding
Oct 3rd, 2016
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either. If an item is clearly documented, you may count it ...
In Billing
Feb 19th, 2016
When billing Medicare, a provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management (E/M) CPT or HCPCS Level II code. For services performed on or after September 10, 2013, however, physicians may use the 1997 documentation guidelines for an extended history of present illness ...
AAPC’s ICD-10 White Paper, “ICD-10: The History,  Impact, and  Keys to Success,” is now available at no cost for members and non-members staring down the implementation of the new code set October 1. The white paper, which discusses the history, benefits, and impact of ICD-10, includes steps to a successful ICD-10 transition. AAPC offers several ...
In Audit
May 27th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA During a recent meeting with approximately 40 providers, I asked how many had billed a level 5 evaluation and management (E/M) visit in the last month.  Not one hand was raised.   How about the last 6 months?   A few hands went up but each of them ...