Advanced Search

Revenue Cycle Insider

E/M Coding:

Use These Tips for Educating Clinicians on MDM

Published on Fri Jun 20, 2025

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

June 2025

ED Coding:
Use These Z Codes Primarily as Primary Diagnoses
Question: I have a rather odd claim in front of me. We are a small [...]

Oncology Coding:
Use This Train of Thought for Coding Monoclonal Antibody Drug Administration
Question: Our team is discussing how to validate the administration code (chemo or non-chemo) for [...]

Path/Lab Coding:
Learn This Lyme Test Lesson
Question: We are currently seeing a greater than normal amount of requests to conduct lab [...]

Orthopedic Coding:
Learn 3 Tips for Optimizing Your Fracture Care Coding Success
Make a cheat sheet for patient billing education. As an orthopedic coder, assigning the correct [...]

General Surgery Coding:
Dissect the Details of Operative Reports
Highlighting procedures from the notes will help you code as you go. Tyler Griffeth’s, MOL, [...]

Pulmonology Coding:
Correctly Report Bronchoscopy Procedures With Multiple Sampling Techniques
Remember to sequence your codes by RVU value. Bronchoscopy procedures are quite common for pulmonology [...]

Ob-Gyn Coding:
Learn 4 Tips to Fix Vulvar Lesion Coding Mistakes Before They Happen
Considering an integumentary code? Avoid making this $178 mistake. Do you know the difference between [...]

Neurosurgery Coding:
Find the Reason for Twist Drill Hole Coding
Question: Encounter notes indicate that the neurosurgeon used a manual twist drill to create a [...]

ICD-10-CM Coding:
Find Answers in These Tricky Transplant Situations
Hint: Check the coding guidance for each transplant-related ICD-10-CM code carefully. Patients who receive organ [...]

Podiatry Coding:
Step Into Foot and Ankle Tendon Transfers 101
Find out what elements factor into code selection. Foot and ankle tendon transfers are surgical procedures [...]

Pediatric Coding:
Don’t Get Burned Coding These Common Summer Health Concerns
With high temps just kicking off, prepare for these fun-in-the-sun encounters. Summer is officially here [...]

Technology & Innovation:
Modify Your Generative AI Model to Enhance Accuracy
Question: I’m worried about our staff members receiving incorrect information from a generative artificial intelligence [...]

Otolaryngology Coding:
Take This Advice, Propel Your DES Placement Understanding
Question: What is the correct coding for endoscopic placement of a PROPEL® drug-eluting stent (DES) [...]

Path/Lab Coding:
Advance Your Understanding of Drug Test Coding, Part 1
Applying the correct code is as easy as understanding the test's purpose. Drug testing makes [...]

Otolaryngology:
Refresh Your Coding Understanding of These Common Pediatric Oral Surgeries
Here’s all the procedure codes you’ll need, with all the Dx codes that go with [...]

Compliance:
Writing Off a Signature Could Cost You
Question: We recently suffered major storms and power outages in my area. All of our office [...]

Anesthesia Coding:
Query for Anatomical Specificity
Question: A provider documented that they performed a popliteal block. I cannot find a CPT® code [...]

Cardiology Coding:
Don’t Forget to Check Excludes1 Notes
Question: A provider diagnosed a 3-week-old patient with an unspecified tachycardia, and I reported R00.0. [...]

Technology & Innovation:
Learn How New Treatments Reach Your Patients – Part 1
Learn the differences between RCTs and NRCTs. New drugs, medical devices, and health advancements are [...]

Neurosurgery Coding:
Perfect Your Coding Skills for Cervical Disc Disorders
Do you know the ins and outs of the M50.- code set? To master coding [...]

Neurology & Pain Management Coding:
ICD-10-CM 2026 Expands MS Coding Options
Also, these neurodevelopmental disorders get new codes. Neurology and neurosurgery coders are going to want [...]

General Surgery Coding:
Nip Lumpectomy Denials With a Z Code
Question: The surgeon performed a breast lumpectomy, but it seems like the only ICD-10-CM codes I’m [...]

Urology Coding:
Spot the Difference Between Incontinence Types
Question: I’m new to coding in a urology office and need to become familiar with [...]

Optometry/Ophthalmology Coding:
Boost Your Understanding of Eye Examination Codes
Apply your code knowledge to real-world scenarios. Ophthalmology and optometry have the distinction of a [...]

Emergency Department Coding:
Know These Differences Between These Office Types
Question: I just started working for a general practice whose physicians see patients in the [...]

Practice Management:
Pocket These Tips for Successful Communication
Hint: Think of language as its own entity, separate from communication. Communication is a basic [...]

Otolaryngology Coding:
Don’t Inflate This Balloon-Dilation Septoplasty Claim
Question: What is the correct way to report an in-office septoplasty by balloon dilation? My [...]

Technology & Innovation:
Treat Heart Failure With an Artificial Replacement
Question: Are any medical devices available to treat patients with critical heart failure while they [...]

Neurology & Pain Management Coding:
Antisocial and Asocial Are Synonymous for This Dx
Question: Encounter notes indicate a patient has an “asocial personality.” Is this the same as [...]

Neurology & Pain Management Coding:
Tilt Table a Must for 95922 Reporting
Question: Could you explain what autonomic nervous system function testing via vasomotor adrenergic innervation is, [...]

Pediatric Coding:
Examine This Encounter Lacking a Diagnosis
Question: Our pediatrician saw a 2-year-old whose father said they had been acting like they didn’t [...]

ICD-10-CM Coding:
Look to Cause When Selecting Dx for Lower Back Pain
Question: A patient came to the office complaining of lower back pain. The physician documented [...]

Urology Coding:
Get Ready for 2026 ICD-10-CM Updates Headed Your Way
Look to the new codes for more specificity on your urology claims. Get ahead of [...]

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. Evaluation [...]

Compliance:
Focus On These Elements to Organize Audit Findings
Make sure you’re comparing apples to apples when calculating accuracy. Communicating the findings of an [...]

General Coding:
Rely on Online Sources to Stay On Top of Updates
Question: I use physical coding books, but have had a few mishaps where a code [...]

Neurosurgery Coding:
Use Specific Paralytic Syndrome Codes When Possible
Question: Encounter notes indicate that a patient suffers from Brown-Sequard syndrome. Should I just report [...]

Optometry/Ophthalmology Coding:
Look to 2026 Codes for Thyroid Orbitopathy Dx Reporting
Question: I have a medical report where the physician diagnosed the patient with thyroid orbitopathy. [...]

Optometry/Ophthalmology Coding:
Get Ready for More Specificity With H01.8
Question: The ophthalmologist diagnosed the patient with right upper eyelid edema due to allergies. What [...]

General Coding:
Try These Alternatives for the ‘Overused’ Modifier 59
Find out how and why to use this modifier the right way every time. Modifier [...]

General Coding:
Define OR for Successful Modifier 78 Use
Question: I work for a surgery practice, and I’ve been using modifier 78 when patients [...]

Cardiology Coding:
Use MI Age to Select Correct Code(s)
Question: I just got a job with a cardiologist’s practice and have learned that the [...]

Emergency Department Coding:
ICD-10-CM 2026: Abdominal Wall, Adverse Effect Dx Codes Coming
Note these new code sets for adverse reaction to dairy/eggs. Coders in emergency departments (EDs) [...]

Podiatry Coding:
Use Code Notes to Populate This DM Foot Ulcer Encounter
Question: I have a report from an encounter with a patient with type 2 diabetes [...]

Podiatry Coding:
Find Out if Aspiration Codes Require Minimum Collections
Question: A patient presented with a soft tissue mass on the left hallux. The provider [...]

Diagnostic Radiology Coding:
Examine the Differences Between Diagnostic Imaging and Radiology
Understand the roles, differences, and importance of diagnosis coding. In healthcare, terms like diagnostic imaging [...]

Oncology Coding:
Make Note of These ICD-10-CM Oncology Revisions for 2026
And take this advice about how to incorporate them. If you were busy and missed [...]

Anesthesia Coding:
Use These Tips for Documentation and Billing of CPT® Code 01996
Hint: You can bill 01996 only once per day. Coders have long struggled with the [...]

ICD-10-CM 2026 Revisions (RCI Bonus Content):
Brace Yourself for ICD-10-CM Changes on the Way
Important coding updates will be here sooner than you think. Beginning Oct. 1, 2025, you’ll [...]

Compliance:
State Law May Require You to Hand Over PHI
Question: If someone from law enforcement is requesting records from our office to investigate a [...]

Medicare Regulations:
Know What’s Coming, According to 2026 SNF PPS Proposed Rule
CMS will try to offset inflation — a bit — with this year’s proposed rate [...]

Pediatric Coding:
Don’t Give Up on This Sleep Apnea Case Prematurely
Question: The pediatrician evaluated a 7-day-old patient who was born prematurely. After assessing the patient’s breathing [...]

Orthopedic Coding:
Define ‘Discrete Structures’ for Shoulder Debridement Procedures
Question: I’m new to orthopedic coding, and I am trying to understand shoulder debridement procedures. [...]

ICD-10-CM Coding:
Look Forward to New Codes for Baked Milk/Egg Tolerance
Question: A physician documented that a patient is allergic to milk and eggs in their [...]

General Surgery Coding:
Free Up This Blocked Artery Procedure
Question: The surgeon treated a patient with a near-complete blockage of the right carotid artery by [...]

Oncology Coding:
Mind Manifestation in This Myelodysplastic Syndrome Situation
Question: The provider documented myelodysplastic syndrome (MDS) and pancytopenia. Under myelodysplastic syndrome in the ICD-10-CM Alphabetic [...]

Pulmonology Coding:
Don’t Overthink a Lower Respiratory Infection Coding Case
Question: What is the code for a viral lower respiratory tract infection? Do I add [...]

Pulmonology Coding:
Learn 3 Different Options to Fix a 31624/31652 Denial
Question: I have a question about a denial we received. The pulmonologist performed a bronchoalveolar [...]

Anesthesia Coding:
Know Which Team Regular Is Considered ‘Clinical’
Question: One of our experienced registered nurses (RNs) regularly serves as an independent observer during [...]

Urology Coding:
Decode This Discontinued Prostate Procedure
Question: The patient was prepped for surgery and put under general anesthesia, after which the urologist [...]

Primary Care Coding:
Understand Primary Care Exception
Question: What’s the criteria for the Centers for Medicare & Medicaid Services (CMS) to recognize [...]

Practice Management:
Look to State Laws for Patient Reimbursement
Question: I’m going through the books at my small, private practice. There are many instances [...]

Primary Care Coding:
Bring Your Measles Coding Up to Speed, Part 1
Don’t overlook the CDC vaccine schedule and your HIPAA practices. If you’ve been paying attention [...]

Orthopedic Coding:
Identify Bilateral and Unilateral OA Knee Codes
Question: A 54-year-old patient presented for a follow-up appointment for their knee pain due to [...]

Path/Lab Coding:
Know the Difference Between These 2 Amplified Probe Codes
Question: When is it appropriate to bill multiple units of 87798 as opposed to billing [...]

Gastroenterology Coding:
Remember to Examine 45330-45347 for Sigmoidoscopy Procedures
Question: Is a flexible sigmoidoscopy incomplete when it is at 30 cm, or is it [...]

Practice Management:
Try Tools for Adjusting Practice Fee Schedules
Question: What resources are available for adjusting the fee schedule for our practice? I used [...]

Diagnostic Radiology Coding:
Code This Cerebral CT Scan Case
Question: A 65-year-old patient presented with memory loss and confusion. The patient’s primary care physician [...]

Medicare Regulations:
Schedule ACP With QHP for Reimbursement
Question: At our practice, registered nurses (RNs) or licensed practical nurses (LPNs) escort patients to [...]

Diagnostic Radiology Coding:
Round Up for Partial A9595 Units
Question: A provider injected a patient with 9.3 millicuries (mCi) of piflufolastat F-18 for a [...]

Gastroenterology Coding:
Find Out the US Imaging Mode for SWE Reporting
Question: I have a gastroenterologist who performed an endoscopic ultrasound (EUS) guided shear wave elastrography [...]

Gastroenterology Coding:
Dig Into Diverticulitis Treatment and Coding Guidelines
Look for bleeding, perforation, or abscess in the notes. Diverticulitis is a painful condition that [...]

E/M Coding:
Track Consultation Code Reimbursement Policies
Question: Providers in my office sometimes perform consultations. We bill these with CPT® codes 99242-99244 [...]

Medicare Regulations:
Confidently Report Resident Care Through End of 2025
Question: Our practice relies on residents to provide some care services. Sometimes we offer patients [...]

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 encounter lasted [...]

Cardiology Coding:
Find Clarity When Coding IV Drug Infusion During This EP Procedure
No surprise: Supporting documentation is crucial to accurately billing +93623. Electrophysiology (EP) ablation studies may [...]

Primary Care Coding:
Use These Codes to Navigate Reporting Parkinson’s Disease
Question: What’s the difference between Parkinson’s disease and secondary Parkinsonism? The primary care provider I [...]

Ob-Gyn Coding:
3 Visits Over 3 Days: What to Do
Question: I have a provider who would like to see new patients over the course of [...]

Ob-Gyn Coding:
Understand the Difference Between Cystectomy and Cyst Removal
Question: Physician said they performed a “cystectomy” with excision and removal of the cyst, but [...]

View All