Advanced Search

Revenue Cycle Insider

E/M Coding:

Check Documentation to See Whether E/M Is Appropriate Alongside Infusion

Published on Thu May 14, 2026

You’ve reached your limit of free articles. Already a subscriber? Log in.

Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:

Simple explanations of current healthcare regulations and payer programs
Real-world reporting scenarios solved by our expert coders
Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
Instant access to every article ever published in Revenue Cycle Insider
6 annual AAPC-approved CEUs
The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

May 2026

Podiatry Coding:
Learn How to Report Nail Avulsion Procedures
Question: A patient presented to the podiatrist with a painful ingrown toenail on the right [...]

Podiatry Coding:
Locate the Correct Plantar Nerve Decompression Code
Question: I have an operative note for decompression of the first branch of the lateral [...]

Diagnostic Radiology Coding:
Remember to Use Symptoms When a Fracture Is Ruled out
Question: I have a radiology report for X-rays of a 36-year-old patient complaining of wrist [...]

Diagnostic Radiology Coding:
Don’t Forget the 7th Character to Report the Treatment Stage
Question: A patient presented for an MRI exam without contrast of their right knee. The [...]

Neurology & Pain Management Coding:
Know Hemiplegia Type Before Settling on Dx
Question: If a patient is suffering from hemiplegia, what ICD-10-CM code should I report? AAPC [...]

Podiatry Coding:
Take The Pain out of Coding Heel Spur Diagnoses
Can you code heel spurs and plantar fasciitis together? Calcaneal spurs, or heel spurs as [...]

General Surgery Coding:
Shoulder up to This Hemiarthroplasty Procedure
Question: What is the correct code to use for a revision of a shoulder hemiarthroplasty [...]

General Surgery Coding:
Go Unlisted for Frey’s Procedure Coding
Question: What is the correct way to report Frey’s procedure? Florida Subscriber Answer: The key [...]

Emergency Department Coding:
Take Traumatic Fracture Diagnoses to the 7th Character
Ensure a complete Dx to aid future patient care. Patients present to the emergency department [...]

Pulmonology Coding:
Distinguish the Core Coding Differences Between PSG and HSAT
Find out when to report symptoms versus diagnoses. As a pulmonology coder, you’re bound to [...]

Pulmonology Coding:
Can You Identify the Right Codes for This Bronchiectasis Case?
Question: A 66-year-old established patient presented for an evaluation of recurrent lower respiratory infections, having [...]

Urology Coding:
Learn How to Report the Transurethral Resection Codes for BPH
Not all TUR procedures treat the prostate. Transurethral resection codes are important urologic procedural codes [...]

Anesthesia Coding:
Look for Combo Code When Tonsillectomy and Adenoidectomy Performed Together
Question: How should you code a combined tonsillectomy and adenoidectomy provided during the same anesthetic [...]

Anesthesia Coding:
Avoid These Common TEFRA Pitfalls in Anesthesia Billing and Documentation
Know the relevant criteria and modifiers for reporting anesthesia services accurately. The Tax Equity and [...]

Practice Management:
Ground Revenue Cycle in Operations Workflow
Aligning a practice’s departments can catch problems early for everyone. When the various departments involved [...]

General Surgery Coding:
Find out When It’s Time to Apply Modifier 22
Hint: This modifier does not apply to routine or minor extensions in complexity. How do [...]

ICD-10-CM Coding:
Check Your Gastroenterology Coding Knowledge With These Scenarios
Navigate sequencing guidelines for gastro patients’ evolving symptoms and diagnoses. Gastroenterology coders are often presented [...]

Compliance:
Use These 3 Lines to Help Team Members Differentiate FWA
Question: I’m going to be onboarding new team members hired to do coding and billing. [...]

Compliance:
Make Mentor/Mentee Relationships Central to Your Compliance Program
Future-proofing your program means building it up internally through knowledge sharing. Compliance departments are being [...]

Compliance:
Dashboards and Reports Are Complementary Tools for Compliance
Question: I’m about to take on compliance officer duties in my organization, and I am [...]

General Coding:
Lean on Modifier 51 for This Scenario With Multiple Procedure Sites
Question: Our general surgeon removed a 2.5 cm benign lesion from the patient’s upper back [...]

Ob-Gyn Coding:
Use 58120 to Report an EMB With Cervical Dilation
Question: I have a report for an endometrial biopsy (EMB) that required cervical dilation due [...]

ICD-10-CM Coding:
Capture This Cystitis Diagnosis With N30.00
Question: An established patient presents to a primary care office with a three-day history of [...]

Diagnostic Radiology Coding:
Skip Sedation for CT Colonography Procedures
Find out if colonography is acceptable for CRC screenings. During a colonography, a radiologist uses [...]

Anesthesia Coding:
Focus on Procedure Rather Than Location
Question: How should you code anesthesia when it is provided in a cardiac catheterization lab? [...]

Otolaryngology Coding:
Know When, and When Not, to Bill Separate E/M With Allergy Tests
Let these 3 scenarios help you achieve clarity in coding this tricky service combo. For [...]

ICD-10-CM Coding:
Detangle Diagnoses to Find Primary Reason for Encounter
Question: A 76-year-old right-handed patient with a history of stroke and left-sided hemiparalysis presented with [...]

Ob-Gyn Coding:
Report a Patient’s LEEP History Along With an O Care Code
Question: A pregnant patient came into our ob-gyn practice for an ultrasound at 16 weeks. [...]

Primary Care Coding:
Stay Informed of the Evolving Nature of Adolescent Preventive Visits
Wake up to the coding reality of adolescent preventive care. Adolescent well visits are no [...]

Optometry/Ophthalmology Coding:
Know When Cataract Treatment Meets a Level 5 E/M
Question: An established senior patient presented to the office for a follow-up evaluation and management [...]

Orthopedic Coding:
Don’t Get Tripped up by This Tendon Injection
Question: I’m the newest coder in my orthopedic office and I need some help. How should [...]

Neurology & Pain Management Coding:
Know the Differences, and Similarities, Among Different TBI Codes
Question: What’s the difference between a diffuse traumatic brain injury (TBI) and a focal one? [...]

Oncology/Hematology Coding:
Take the Precision Oncology Coding Challenge
Here’s how to understand CPT® and ICD-10-CM coding for cancer genetic testing. Precision medicine is [...]

Gastroenterology Coding:
Use These 5 Steps to Code Colon Polyps When Pathology Is Pending
Coding an adenoma before pathology confirms the diagnosis is a big mistake. When you’re coding [...]

Orthopedic Coding:
Stay Hip to These Arthroplasty Approaches
Expert: “The best approach is the one your surgeon is the most familiar with.” When [...]

Ob-Gyn Coding:
Use This Advice for Dx Sequencing for a Viability Ultrasound in an AMA Pregnancy
Beware of reporting AMA without trimester specificity. A subscriber recently asked, “If a patient presents [...]

Neurosurgery Coding:
Specificity Matters on Craniosynostosis Dx
Question: Encounter notes indicate that a newborn patient suffers from craniosynostosis. How should I choose [...]

Optometry/Ophthalmology Coding:
Simplify Your Complicated Cataract Coding Confusion
Know when to report complex versus standard cataract surgery. As the human eye ages, the [...]

Primary Care Coding:
Find Clarity on Cellulitis Encounter
Question: An established patient presents with a three-day history of increasing redness, warmth, swelling, and [...]

Neurology & Pain Management Coding:
Use This Guide to Tame PET Scan Coding Fears
Remember to note the drug supply type, as coding depends on it. There are high [...]

Neurosurgery Coding:
Know How Surgeon Created Hole for Drain Placement Coding Success
Question: Encounter notes indicate that the surgeon “created Burr hole/placed EVD via Burr Hole to [...]

Optometry/Ophthalmology Coding:
Choose the Correct Conjunctivitis Code
Question: A 31-year-old established patient presents to their optometrist with itchiness and redness in both [...]

Pediatric Coding:
Correctly Code This Dental Service in Your Medical Office
Question: My pediatric provider has just started offering fluoride varnish applications preventively to patients. Is this [...]

Path/Lab Coding:
Know These Estrogen Receptor Testing and Status Coding Nuances
Question: How do I report estrogen receptor (ER) testing, and what is the correct ICD-10-CM [...]

Cardiology Coding:
Capture the Relevant Codes for Follow-Up to Monitor Digoxin Levels
Question: A 62-year-old established patient presents for a scheduled follow-up after being prescribed digoxin for [...]

Oncology/Hematology Coding:
Look to These Documents for Correct Chemo Pump Coding
Question: Can you point to any documentation that shows 96416 is not the correct code [...]

General Coding:
Know Your Respective Entities’ TIN to Determine Modifier Necessity
Question: I am extremely new to billing and coding. I work in a family practice [...]

Urology Coding:
Understand How to Code UPEC Infection With Cystitis
Question: Patient presented with complaints of frequent urination and pain while voiding their bladder. The [...]

Orthopedic Coding:
Take An Expert’s Advice on This Knee Procedure
Question: My practitioner just performed a knee meniscectomy. How should I code this procedure? 2026 [...]

E/M Coding:
Check Documentation to See Whether E/M Is Appropriate Alongside Infusion
Question: I work for a rheumatology office. Sometimes patients come in for an infusion but [...]

Practice Management:
Know Which Staff Are Subject to FLSA
Question: I’m in charge of scheduling employees and need to figure out what’s best for [...]

Pulmonology Coding:
Identify Which Systems Are Affected by Hantavirus Before Coding
Question: What are the codes to assign for a hantavirus diagnosis? Revenue Cycle Insider Subscriber [...]

Pediatric Coding:
Don’t Stress When Coding This Dislocation Encounter
Question: A 5-year-old patient recently presented with a dislocated left elbow. After examination, the pediatrician confirmed [...]

Path/Lab Coding:
Know Which Tests Help Distinguish Crohn’s From UC
Question: A provider ordered tests for a patient with inflammatory bowel disease (IBD). The patient [...]

E/M Coding:
Query the Experts First on Low-Risk MDM
Question: The CPT® medical decision making (MDM) table provides examples under the moderate- and high-risk categories, [...]

Gastroenterology Coding:
Learn How to Bill a Deferred Polypectomy
Question: A patient with APC I1307K had a screening colonoscopy in October 2025. The provider [...]

Medicare Regulations:
Don’t Issue ABNs to Patients With Medicare Advantage Plans
Question: Can we issue an advance beneficiary notice (ABN) document to patients with Medicare Advantage [...]

In Case You Missed It (RCI Bonus Content):
Get a Head Start on These New CPT® Codes
And note these changes to these Category III, PLA codes. The American Medical Association (AMA) [...]

Primary Care Coding:
Let the Experts Handle This Case
Question: I’m relatively new to coding. How should I code the following visit?: Chief complaint: [...]

Urology Coding:
Remember That Navigable Does Not Always Mean Steerable
Question: We’ve seen several cystourethroscopy cases enter our coding workflows over the past year, and [...]

Cardiology Coding:
Know How to Code a Diagnostic Study Versus Stent Placement
Question: How do you code a diagnostic coronary angiography with stent placement? South Carolina Subscriber [...]

Otolaryngology Coding:
Know When to Append a Bilateral Modifier to These Unilateral Services
Question: My new employer is insisting that the only way Medicaid will pay for removal [...]

Technology & Innovation in Healthcare:
Does AI Work in Small Offices?
Question: I keep hearing about how large healthcare organizations or hospitals are using artificial intelligence [...]

Otolaryngology Coding:
Know the Score With This Unlisted Simple Snoring Procedure
Question: What code should we be using for injection snoreplasty? AAPC Forum Participant Answer: Injection [...]

Medicare Regulations:
Try Modifiers PN, PO for Provided-Based Billing at an Outpatient Facility
Question: A Medicare beneficiary with diabetes presents to an outpatient wound care clinic for treatment [...]

Practice Management:
Wait for New Insurance Card for Name Changes
Question: A patient came in and announced that they’d gotten divorced and asked front desk [...]

Oncology/Hematology Coding:
Know the Difference Between These Inactive Cancer Codes
Question: When a patient comes back to our office after their cancer has been completely [...]

Emergency Department Coding:
Eye FBR Claims for E/M Evidence
Question: A patient presents to the emergency department (ED) complaining of pain in their right [...]

Technology & Innovation in Healthcare:
Defend Doctors Against AI Deepfakes
Question: Are fake videos created with artificial intelligence (AI) becoming a real risk in healthcare [...]

General Coding:
Differentiate Payer Rules to Collect for Surgical Complications
Remember that Medicare requires a return to the operating room before reimbursing these services. Not [...]

Neurosurgery Coding:
Know How to Report Intracranial Aneurysm Repairs
Zeroing in on the number of aneurysms can be misleading. When you code neurosurgical procedures, [...]

Technology & Innovation in Healthcare:
Simplify Cervical Cancer Screening With At-Home Kits
Key reminder for ob-gyn coders: You won’t be billing the lab codes. Patients coming into [...]

Path/Lab Coding:
Let OSHA Be Your Guide to Safety in the Lab
Make sure your lab is free of hazards in these four critical areas. If you [...]

Gastroenterology Coding:
Identify the Correct Z Code for a Surveillance Colonoscopy
Question: When a patient comes in for a surveillance colonoscopy with an initial diagnosis of [...]

Emergency Department Coding:
Look for Anatomic Details Before Choosing Cyst Code
Question: When a patient reports to the emergency department (ED) with a ganglion cyst, what [...]

Medicare Regulations:
Know the Ins and Outs of Medicare Coverage and Eligibility Verification
Verification mishaps can cost your practice time and money. Providers verify Medicare coverage using various [...]

E/M Coding:
Follow These Rules of Thumb for Coding E/M or Psychiatric Evaluation — Part 2
Find more tips on distinguishing psychiatric evaluations from E/M services. Accurate evaluation and management (E/M) [...]

Cardiology Coding:
Coding a Discontinued Ablation: What You Should Report — And What You Shouldn’t
When the electrophysiologist stops an ablation mid-procedure, look to these modifiers. Catheter ablation procedures are [...]

View All

Subscribe to newsletter