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E/M Coding:

Become an Exceptional E/M Coder via Expert Advice

Published on Thu Aug 20, 2026

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Other Articles of

August 2026

Pulmonology Coding:
Assign Signs and Symptoms Codes When the Pathology Hasn’t Returned
Question: A patient presented to our pulmonology practice with a chronic dry cough and exertional [...]

General Surgery Coding:
Identify Margins, Measurements, and Malignancy for WLE Coding
Also, learn how to navigate closures and modifiers for malignant lesion excision. A wide local [...]

Emergency Department Coding:
Remove the Coding Confusion With Drainage and FBR Smarts
Do you know what makes a foreign body removal procedure simple versus complicated? If documentation [...]

Neurology & Pain Management Coding:
Know How to Line up Providers With Proper EEG Codes
Physicians and technologists have their own CPT® codes for these tests. When a patient presents [...]

Neurosurgery Coding:
Use Coding Knowledge to Stabilize Cranial Tong/Halo Applications
Be sure to count the number of pins the surgeon inserts on cranial halos. Patients [...]

RCI Bonus Content:
Check out the 2027 CPT® Changes That Could Impact Your Coding
Be ready for one of the largest CPT® revisions in recent history. With 300 new [...]

Optometry/Ophthalmology Coding:
Avoid Confusing PCO Treatment With Cataract Surgery
Can you report YAG capsulotomy and cataract surgery on the same DOS? Sometimes, a cataract [...]

ICD-10-CM Coding:
Sequence the Injury Code Before the External Cause Code
Question: A 5-year-old established patient presents to their family physician’s office with their parent after [...]

Podiatry Coding:
Don’t Slip up When Distributing Diabetic Shoes
Question: Our podiatrist examines the patient, prescribes therapeutic diabetic shoes, and then provides the shoes [...]

Primary Care Coding:
Use This Guidance to Document Work Involved in Care Coordination
Know how to code behind-the-scenes communication between providers. Providers often need to communicate with one [...]

Anesthesia Coding:
Consider Distinct Billing Challenges for Complex Cardiac and Neurosurgical Anesthesia
Hint: Reporting provider relief involves capturing time units accurately. Coding anesthesia for complex cardiac and [...]

ICD-10-CM Coding:
Be Careful Coding a Localized Reaction to a Bee Sting
Question: A patient presents to the physician’s office with an extremely swollen foot after a [...]

Neurosurgery Coding:
Be Aware of the Many Ways Auras Can Impact Migraine Patients
Question: A patient with migraine reports a darkening around the edges of their visual field [...]

Primary Care Coding:
Don’t Be Stymied When Coding This Red-Eye Encounter
Question: An established 42-year-old patient presents to a family medicine office with two days of [...]

Practice Management:
Keep Online Scheduling From Creating Access and Privacy Problems
Question: Our multispecialty practice recently enabled online scheduling through the patient portal. A patient selected [...]

Practice Management:
Don’t Automatically Bill Patients After a Denial
Reader Question: Our orthopedic practice obtained prior authorization from a patient’s Medicare Advantage (MA) plan [...]

Pulmonology Coding:
Identify a Solitary Pulmonary Nodule Code for This Chest CT Case
Question: A new senior patient presented to the pulmonology practice after an opacity in the [...]

Otolaryngology Coding:
Use This Coding Combo for Ear Abscess and Eardrum Perforation
Question: One of our providers diagnosed a patient with an acute recurrent abscess of the [...]

Technology & Innovation in Healthcare:
Provide Seniors With the Medical Care They Need in the Home They Love
Know when your patient last ate with in-home monitors. With an approximately 16 million senior [...]

Neurology & Pain Management Coding:
Scour Inclusion Terms Before Settling on ‘Other’ MD Dx
Question: Encounter notes indicate that the physician treated a patient with “Emry-Dreyfuss MD.” I’m pretty [...]

Anesthesia Coding:
Understand ‘Trained Observer’ Role in Anesthesia Procedures
Question: Sometimes a trained observer monitors the patient undergoing sedation while a physician performs the [...]

Path/Lab Coding:
Get a Handle on HPV Test Coding
Question: Can you explain the difference between the human papillomavirus (HPV) tests? Revenue Cycle Insider [...]

General Surgery Coding:
Reduce Coding Confusion Surrounding Inguinal Hernia Repair
Question: A 58-year-old patient presented for surgery on a right inguinal hernia. The patient had [...]

Pulmonology Coding:
Bolster Your Coding Knowledge for BLVR Procedures
Know when a diagnostic bronchoscopy is bundled. Bronchoscopic lung volume reduction (BLVR) with endobronchial valve [...]

Compliance:
Nurture a Culture of Compliance to Prioritize Integrity
Make sure workers do what’s right, even when no one is watching. Compliance should be [...]

Pediatric Coding:
Identify the Signs and Symptoms of Celiac Disease
Before a diagnosis is determined, coding can be tricky. You’ve probably encountered numerous claims and [...]

Cardiology Coding:
Code Hyperlipidemia Management to the Documented Specificity
Question: An established 68-year-old patient returns to the cardiology office for follow-up of atherosclerotic heart [...]

Neurosurgery Coding:
Keep Anatomy in Mind When Coding Nerve Injections
Question: When the surgeon performs an autonomic nerve injection with an anesthetic agent, how should [...]

Podiatry Coding:
Code This Arthrocentesis Procedure Correctly
Question: A 57-year-old established patient came into our office with complaints of increasing pain, swelling, [...]

Medicare Regulations:
See CMS Telehealth Guide for Enrollment Questions
Question: I am trying to navigate the process to get my provider set up for [...]

Compliance:
Know When a Coding Audit Finding Belongs in the Board Report
Question: One of our three outpatient practices has missed our 95 percent coding accuracy target [...]

Ob-Gyn Coding:
Don’t Use an O Code When Obesity Isn’t Documented as a Pregnancy Complication
Question: A patient who is six weeks pregnant presents with pelvic pain on their right [...]

Orthopedic Coding:
Recognize How to Report Primary vs. Secondary Achilles Tendon Reconstruction
Find out how you need to document grafts. Orthopedic coders frequently encounter varying terminology when [...]

Diagnostic Radiology Coding:
Press the Brakes on AI Adoption, Says the ABR
Question: The growth and adoption of artificial intelligence (AI) in healthcare is impressive. I understand [...]

Urology Coding:
Try Your Skills at Coding Kidney Procedures
See how you score with this nephrectomy quiz! When it comes to nephrectomy coding, the [...]

General Surgery Coding:
Recognize How to Code This Rapidly Spreading Infection
Question: A 63-year-old patient presented to the emergency department (ED) with severe perineal pain and [...]

Diagnostic Radiology Coding:
Do You Use M79.89 or R22.- to Report Swelling in the Leg?
Question: I have a radiology report for three-view X-rays of a patient’s lower left leg, [...]

Cardiology Coding:
Know the Nitty-Gritty of Modifier Use in Cardiology
Find out how to limit your audit risk by navigating modifier guidelines. Modifiers can be [...]

E/M Coding:
Become an Exceptional E/M Coder via Expert Advice
A few specific details in your practitioner’s notes can make all the difference. When it [...]

General Coding:
‘The Physician Talked to the Patient’ Is Not Enough for Modifier 25
Question: An established patient presents for a diagnostic procedure. Before the procedure begins, the physician [...]

E/M Coding:
Don’t Get Hung up on Phone Visit Coding
Question: Our provider, Dr. Thompson, completed a phone visit with an established patient for chronic disease [...]

General Coding:
Don’t Use a Modifier Just to Override a NCCI Edit
Question: A patient with atherosclerotic heart disease undergoes a diagnostic cardiac catheterization 93458 (Catheter placement [...]

Cardiology Coding:
Don’t Append Modifier 26 When You Performed the Global Service
Question: A cardiology practice performs an echocardiogram on a patient with chronic diastolic (congestive) heart [...]

Otolaryngology Coding:
Take This Advice for Accurate Nasal Ablation Coding
Know the major mistakes to avoid. Chronic rhinitis (CR) is persistent inflammation or dysfunction of [...]

Gastroenterology Coding:
Evaluate This EGD and Stricture Dilation Coding Conundrum
Question: A 68-year-old patient with longstanding gastroesophageal reflux disease (GERD) and esophagitis presented with worsening [...]

Diagnostic Radiology Coding:
Learn Why Radiologists Use Dual-Energy CT to Evaluate Patients
Plus: You’ll be surprised by how to code DECT procedures. Dual-energy computed tomography (DECT) is [...]

Optometry/Ophthalmology Coding:
Recognize How to Code a Rust Ring Removal Procedure
Question: A 63-year-old patient presented to the emergency department (ED) thinking they had a fleck [...]

General Coding:
Check Payer and CLIA Information Before Appending Modifier QW
Question: I work for an outpatient office where providers regularly perform and interpret in-house testing [...]

General Coding:
Find out Why CPT® Category II Codes Matter More Than Ever
Value-based care involves painting a more complete picture for payers. Value-based contracts for care are [...]

Neurology & Pain Management Coding:
Use 1 Code for 4-Limb EP Study
Question: A 34-year-old reports months of numbness and tingling in both hands and feet, now [...]

Emergency Department Coding:
Get Acquainted With Dx for Cyclosporiasis, Other Foodborne Infections
Question: What is the proper ICD-10-CM code for cyclosporiasis? With all I’m hearing about it [...]

Oncology/Hematology Coding:
Use This Code Sequence for Palliative Chemotherapy Aftercare
Question: A patient came back to us following palliative chemotherapy for primary liver cancer. Is [...]

Primary Care Coding:
Report Signs and Symptoms for This Swollen Knee Presentation
Question: A provider’s documentation says an established patient presented with right knee pain and swelling [...]

Path/Lab Coding:
Tally AI’s Sway on Lab Operations
Understand the forthcoming changes to Appendix S By any other name, artificial intelligence (AI) is [...]

Anesthesia Coding:
Choose the Tympanotomy Code for Pediatric Ear Tubes
Question: A 4-year-old child with recurrent otitis media undergoes bilateral myringotomy with tympanostomy tube placement. [...]

E/M Coding:
Know When to Use an E/M Code in Place of a CPO Code
Question: We have a patient who is currently eligible for home-based care, and our oncologist [...]

Orthopedic Coding:
Face This Fasciectomy Procedure With Confidence
Question: There’s a conflict between the professional and technical coding for this procedure. The provider [...]

Orthopedic Coding:
Examine This EIP to EPL Tendon Transfer Coding Case
Question: I have an operative note for an encounter where the orthopedic surgeon performed a [...]

Emergency Department Coding:
Remember to Code Needle Decompression for This eFAST Exam
Question: A patient presents to the emergency department (ED) with respiratory distress, hypotension, and a [...]

Otolaryngology Coding:
Don’t Roll the DISE With This Code Choice
Question: I am trying to find the right code for a drug-induced sleep endoscopy (DISE). [...]

Practice Management:
Focus on the Data to Help Optimize Revenue
AI is here to stay, and organizations will embrace the technology or risk being left [...]

Oncology/Hematology Coding:
Use These 2 Codes for Pancoast Tumor Pain Management
Question: We treated a patient for severe pain due to a Pancoast tumor. How should [...]

Medicare Regulations:
Get Ready for the Relaunch of PEPPER!
See how the program can help with compliance efforts. The Centers for Medicare & Medicaid [...]

Medicare Regulations:
Do You Understand Inpatient Admission Criteria? Find out
Question: I am reviewing an inpatient medical record, and the attending physician documented the following: [...]

Gastroenterology Coding:
What Do You Do When ‘Screening’ Isn’t Supported by the Medical Record?
Do not assume the heading on the procedure report tells the entire story. Documentation drives [...]

Urology Coding:
Navigate This Wandering Testicle Case
Question: A 32-year-old presents to our urology clinic with concerns about intermittent movement of their left [...]

Path/Lab Coding:
Location Key to This Test Denial
Question: We just received a denial for 80307 with place of service (POS) 22. Why [...]

Pediatric Coding:
See How Hypoxia and Hospitalization Discussions Affect E/M Selection
Question: Our pediatrician evaluated a 9-month-old established patient whose parent reported three days of cough, [...]

ICD-10-CM Coding:
All in the Timing: Coding Essentials for Acute, Chronic, and Acute-On-Chronic Conditions
Hint: Not all recent symptoms indicate acute status. Coders rely on provider documentation to determine [...]

Optometry/Ophthalmology Coding:
Will Society Guidance and AI Combine to Streamline Clinical Decision Making?
Question: With new studies, treatment options, and diagnostic technologies emerging regularly, how can ophthalmology practices [...]

Oncology/Hematology Coding:
Know How to Avoid Compliance Pitfalls and Support Accurate Cancer Dx Coding, Part 2
Understand how to document and support active or history Dx coding. In part 1 of [...]

Podiatry Coding:
Pinpoint How to Code Neuroma Removal Procedures
Find out the difference between regular and Morton’s neuromas. Per the American Podiatric Medical [...]

Urology Coding:
Don’t Let Lithotripsy Confuse Your Stone Removal Coding
Question: My urologist removed a kidney stone through a percutaneous approach, but the radiology department [...]

Pediatric Coding:
Get a Handle on Hand, Foot, and Mouth Disease
Question: A parent brings their 4-year-old child to the family pediatrician’s office after the child [...]

Technology & Innovation in Healthcare:
Provide Gestational Diabetes Care for Rural or Underserved Pregnant Patients
Question: As our organization works to improve maternal health outcomes, we are exploring novel approaches [...]

Ob-Gyn Coding:
Avoid Coding Errors for Endometriosis Involving the Bowel
Question: I’m coding an operative report for a patient with severe endometriosis. During the procedure, [...]

Gastroenterology Coding:
Code This Colonoscopy Following a Positive FIT Result
Question: I read the Revenue Cycle Insider article, “Check out These 7 Steps to [...]

Technology & Innovation in Healthcare:
Find out When Audio-Only Visits Still Qualify for E/M Payment
Question: I’m reviewing a telehealth encounter where the provider documented a 15-minute audio-only visit with [...]

Ob-Gyn Coding:
Find out What Every OB Coder Needs to Know About the 2027 Maternity Coding Reset
Say goodbye to bundled procedures and hello to individual service codes. Effective Jan. 1, 2027, [...]

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