E/M Coding & Reimbursement Alert

E/M Coding & Reimbursement Alert - 2025_January

E/M Coding:
Understand the Importance of History Documentation for E/M Coding
Remember the eight components of HPI when you're looking at documentation. Since the eval... Read more

E/M Coding:
Keep These Tips in Mind When Leveling Time
Question: Which aspects of a provider's services count for time when leveling evaluation a... Read more

E/M Coding:
Focus on Date for Problems Addressed, Unaddressed
Question: When I'm looking at a patient's medical record, how do I know whether the provid... Read more

E/M Coding & Reimbursement Alert - 2025_February

E/M Coding:
Code Level 4 E/M for Strep? Not so Fast
Consider CPT® definitions of systemic symptoms for precise coding. When the AMA revised ... Read more

E/M Coding:
Don’t Let Technical Difficulties Ruin Your Claim
Question: If a telehealth visit was converted to an audio-only visit due to technical diff... Read more

E/M Coding:
Does a New Setting Determine Patient Status?
Question: I have a situation where our nurse practitioner (NP) performed a new visit for i... Read more

E/M Coding & Reimbursement Alert - 2025_March

E/M Coding:
Distinguish Between Mentions and Discussions
Question: A provider wrote that they made a diagnosis and then discussed with the patient ... Read more

E/M Coding:
Patient’s Decision Doesn’t Change the Work Involved
Question: A provider advised a patient to begin a medication and instructed them on the co... Read more

E/M Coding:
Update Your Code Books With CPT® Errata and Technical Corrections
Keeping resources current will help prevent inaccurate coding of medical services. The AM... Read more

E/M Coding & Reimbursement Alert - 2025_April

E/M Coding:
Don’t Count on Reimbursement for Nonphysician EMR Adjustments
Question: If a clinical staff member or scribe makes entries into a patient's medical reco... Read more

E/M Coding:
Use These Strategies to Educate Providers, Part 1
Feel confident that you have knowledge to offer. Coders may have nightmares about the awk... Read more

E/M Coding:
Understand What Services Are Included in Debridement Procedure
Question: A patient comes in for a wound debridement appointment every week. According to ... Read more

E/M Coding & Reimbursement Alert - 2025_May

E/M Coding:
Don’t Upcode This Low-Level Follow-Up
Question: I'm coding a follow-up encounter for a patient who experienced a neck injur... Read more

E/M Coding:
Expect Denial When Reporting 2 E/M Services on Same DOS
Question: One of our physicians saw a patient in the morning, and then again in the aftern... Read more

E/M Coding & Reimbursement Alert - 2025_May

E/M Coding:
Incorporate These Strategies Into Your Provider Education
Common sense: Adapt your educational content to your audience. Teaching providers about e... Read more

E/M Coding & Reimbursement Alert - 2025_June

E/M Coding:
Fight for Your Right — if the Documentation Supports Your Claim
Question: My billing department billed CPT® code 99214 for an established patient whose e... Read more

E/M Coding:
Track Consultation Code Reimbursement Policies
Question: Providers in my office sometimes perform consultations. We bill these with CPT®... Read more

E/M Coding:
Use These Tips for Educating Clinicians on MDM
Hint: Add examples to your presentation so clinicians can see exactly what you mean. Eval... Read more

E/M Coding & Reimbursement Alert - 2025_July

Evaluation and Management:
Don’t Use Prolonged Services Codes for Calls
Question: I'm reading documentation notes and see that a provider had a 40-minute phone ca... Read more

E/M Coding:
Bill an E/M for This Follow-Up Situation
Question: A provider saw a patient and performed a procedure, which had 0 global days, and... Read more

E/M Coding:
Remember Necessity and Criteria to Bill Incident-to
See how you can bill more services at 100 percent of the physician fee schedule instead of... Read more

E/M Coding & Reimbursement Alert - 2025_August

E/M Coding:
Point Providers to E/M Differences
Question: A provider asked whether they can adjust their evaluation and management (E... Read more

E/M Coding:
Include Additional Info When Billing E/M Services by PA or NP
Question: I work in a multispecialty practice that has different providers, including nurs... Read more

E/M Coding:
Find More Nitty-Gritty Details on Incident-To Requirements
Incident-to services are only appropriate for established patients and problems. If you'r... Read more

E/M Coding & Reimbursement Alert - 2025_September

E/M Coding:
The Documentation Divide: What Separates a 99213 from a 99214
Shoring up your coding with documentation can prevent payer downcoding in acute illness en... Read more

E/M Coding:
Know When to Use Modifier 25 With a Minor Procedure
Question: I often see providers performing minor procedures (like lesion removals or joint... Read more

E/M Coding:
Determine New vs. Established Patient for E/M Coding
Question: Our providers sometimes request that we bill a new patient evaluation and manage... Read more

E/M Coding & Reimbursement Alert - 2025_October

E/M Coding:
Navigate NCCI Edits and Payer Policy to Understand Denial
Question: We are receiving denials for CPT® code +99417 indicating included. We are billi... Read more

E/M Coding:
Code This Tick Removal Encounter
Question: How should I code the following encounter? A 12-year-old established patie... Read more

E/M Coding:
Code Labs and Tests Toward MDM With Confidence
Hint: You must meet two of the three elements to meet a specific level of MDM. Even the m... Read more

E/M Coding & Reimbursement Alert - 2025_November

E/M Coding:
Look for Data Elements to Count Discussions Toward E/M
Question: I code for physicians who see inpatients and collaborate with other providers on... Read more

E/M Coding:
Pay Attention to Time for This New Patient E/M
Question: A provider saw a new patient and spent 44 minutes at the encounter. The provider... Read more

E/M Coding:
Use These Tips to Distinguish Inherent From Separate Services
Make sure you can survive a modifier 25 audit with these tips. Modifier 25 (Significant, ... Read more

E/M Coding & Reimbursement Alert - 2025_December

E/M Coding:
Find Even More Tips for Distinguishing Inherent From Separate Services
Find out what information you need to append modifier 25 correctly and with confidence. M... Read more

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