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Compliance:

Remain HIPAA Compliant While Transitioning to Digital

Published on Wed Nov 05, 2025

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Other Articles of

November 2025

General Coding:
Find Clarity in Wound Care Coding
Here’s what you need to know regarding diagnosis documentation and reporting for wound care. Coding [...]

Neurosurgery Coding:
Know Vertebroplasty/Kyphoplasty Differences for Correct Coding
Affected bone being elevated? That’s a kyphoplasty. Kyphoplasty and vertebroplasty are minimally invasive procedures used [...]

Optometry/Ophthalmology Coding:
Get to Know Uveitis and How to Code the Diagnosis
Question: I’m new to ophthalmology coding and have an encounter note where the physician diagnosed [...]

Cardiology Coding:
Know These Qualifications for Medicare-Covered TTVR Surgery
Question: A colleague mentioned that the Centers for Medicare & Medicaid Services (CMS) provides reimbursement [...]

Technology & Innovation in Healthcare:
Learn if Human Intelligence Is Still Necessary With Transcription
Question: The practitioners I work with are using artificial intelligence (AI) to transcribe their notes [...]

Practice Management:
Working Together Is Key for Timely Filing
Question: When it comes to high-dollar claims, do you differentiate between timely filing and timely [...]

Diagnostic Radiology Coding:
Brighten Your Understanding of Coding Sunrise X-ray Views
Question: What CPT® code should we use for bilateral sunrise views of knees? The patient [...]

Diagnostic Radiology Coding:
Teach AI to Compare Mammogram Views – Part 1
Discover how AI is trained to read mammograms like a radiologist. The mammogram screening process [...]

Path/Lab Coding:
Navigate Reproductive Medicine Lab Codes for Clean Claims
Account for each step in cases that may span years. To establish a healthy pregnancy, [...]

Orthopedic Coding:
Reduce Your Coding Confusion for 3 Common Shoulder Injuries
Find out the common term for adhesive capsulitis. The shoulder is one of the most [...]

Orthopedic Coding:
Know Your Options for This Shoulder Resurfacing Procedure
Question: I have a report for a patient who had a previous shoulder resurfacing procedure [...]

ICD-10-CM Coding:
Follow These Steps to Code an SCFE Injury
Question: An adolescent patient presented with a right hip injury and the provider documented a [...]

Oncology/Hematology Coding:
Get the Answers to These Frequently Asked Sickle Cell Disease Questions
Here’s how to handle reporting SCD crises. Sickle cell disease (SCD) “affects more than 100,000 [...]

Oncology/Hematology Coding:
Look to Neuroendocrine Features for Correct SCC Coding
Question: In my research I have learned that small cell carcinomas are considered a neuroendocrine [...]

General Surgery Coding:
Is 97597 Appropriate for Selective Mechanical Debridement?
Question: Physician’s op note states “Mechanical debridement of biofilm to the level of subcutaneous tissue [...]

General Surgery Coding:
Learn How to Code Intraoperative Complications Correctly
Question: I have an operative note that states the patient suffered an intraoperative complication involving [...]

General Surgery Coding:
Remove Any Confusion With Answers to These 5 Debridement FAQs
Do burn debridement procedures have their own codes? Removing unhealthy or dead tissue from a [...]

Neurology & Pain Management Coding:
Follow Coding Steps for Neuropathy With Underlying Disease
Question: Encounter notes indicate a patient suffers from autonomic neuropathy caused by drug-induced gout of [...]

ICD-10-CM Coding:
Find Correct Code for Folate Deficiency Diagnosis
Question: A provider saw a 35-year-old patient who complained of fatigue. The patient’s record showed [...]

Path/Lab Coding:
Look to Provider Documentation to Code Elevated PSA
Question: A patient’s prostate-specific antigen (PSA) test showed a level that was higher than their [...]

Path/Lab Coding:
Report Pathologist, Not Provider, Findings for This EGD Procedure
Question: The surgeon submitted a stomach biopsy of “inflamed tissue” from an esophagogastroduodenoscopy (EGD) procedure for [...]

Gastroenterology Coding:
Find Out if CPT® 2026 Has New Gastroenterology Codes
Question: Are there any new gastroenterology procedure codes taking effect on Jan. 1, 2026? Revenue Cycle [...]

Gastroenterology Coding:
Look to the 6th Character to Specify a Barrett’s Esophagus Diagnosis
Question: An established patient with Barrett’s esophagus came in for a surveillance visit. The gastroenterologist [...]

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, [...]

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 [...]

General Coding:
Use These Resources for Educational Conversations
Question: I’m an auditor who works with both coders and providers who want to do [...]

General Coding:
Use These Tips When Coding a Problem During a Well Visit
Question: A 48-year-old patient presents to their gynecologist for an annual preventive services visit but [...]

Anesthesia Coding:
Dive Deep on Nerve Blocks for Postoperative and Chronic Pain
Hint: In some situations, you need to know whether the surgeon requested a block. Postoperative [...]

Medicare Regulations:
Use These Tools to Check Eligibility
Question: We regularly see new patients, many of whom are Medicare beneficiaries. I know beneficiaries [...]

Anesthesia Coding:
Use 01402 for This Knee Surgery Anesthesia Service
Question: How should I code anesthesia services for a total knee arthroplasty on a 59-year-old patient? [...]

In Case You Missed It (RCI Bonus Content):
Deliver Proper Coding for Enteral Nutrition
Medicare coverage, medical necessity, and supplies all weigh in. Enteral nutrition is a method of [...]

Primary Care Coding:
Rely On These Codes When Reporting Portal Communication
Question: The primary care physician (PCP) I work for had a conversation with an established [...]

Neurosurgery Coding:
Know Neurofibromatosis Type Before Choosing Dx
Question: A patient reported to the neurosurgeon for an osteotomy of the thoracic spine to [...]

Technology & Innovation:
Recognize the Differences in Remote Patient Monitoring Types
Pay attention to your documentation when billing RPM. Healthcare practitioners often use remote patient monitoring [...]

Anesthesia Coding:
Find Codes for Anesthesia Servies During Bypass Surgery
Question: One of the anesthesiologists I work with began a cardiopulmonary bypass case without the [...]

Podiatry Coding:
Code This Hyperkeratotic Lesion Removal Case
Question: A podiatrist saw a Medicare patient with diabetes and evaluated the patient’s feet. The [...]

Practice Management:
Hold Onto Your Money From High-Dollar Claims
Inspire your team with tips to keep funds in your practice’s pocket. With almost $20 [...]

Primary Care Coding:
Rely On Discrete Documentation for Specific Encounter
Question: One of the primary care physicians (PCPs) I work for documented a visit: a [...]

Gastroenterology Coding:
Follow These CRC Testing Requirements to Bolster Your Claims – Part 1
Learn how often patients are eligible for a screening. Correctly coding colorectal cancer (CRC) screenings [...]

Neurology & Pain Management Coding:
Remember to Code This Epilepsy Type to the 6th Character
Question: Encounter notes indicate that an epileptic patient suffers from attacks “w/no altered consciousness.” Is [...]

Urology Coding:
Learn How to Assign R97.20 for Elevated PSA Values
Question: A 55-year-old patient presented to the urologist for a prostate specific antigen (PSA) screening. [...]

Optometry/Ophthalmology Coding:
Are 11440-11446 Appropriate for Chalazion Excisions?
Question: I have an op note that indicates the surgeon excised two chalazions from the [...]

Pulmonology Coding:
Watch Out for Double Billing on COVID-19 Vaccine Administration
Question: An established patient presented for a routine follow-up visit concerning their moderate persistent asthma. [...]

Orthopedic Coding:
Learn if 29806 or 29827 Are Needed for a Remplissage Procedure
Question: The orthopedic surgeon performed arthroscopic shoulder labral repair and remplissage on the patient’s right [...]

Medicare Regulations:
Consider Dx Complexity When Billing G2211
Question: I think the code descriptor for G2211 makes it seem like a coder can’t [...]

Compliance:
Tighten Up Your E-Signature Security
Question: During a recent risk assessment audit, it was found that our e-signatures, including those used [...]

Urology Coding:
Can You Bill Catheter Exchange and Injection Procedures Separately?
Question: A patient came in for a Botox injection in their bladder, which happened through [...]

Pediatric Coding:
Inflate Your Asthma Expertise
Remember to include a 5th character when coding an asthma diagnosis. With roughly 4.9 million [...]

Oncology/Hematology Coding:
Consider Cause in This Cancer Anxiety Coding Conundrum
Question: Our providers often address the patient’s anxiety related to their new cancer diagnosis. Would [...]

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 patient [...]

Technology & Innovation:
Copy and Paste Isn’t All It’s Cut Out to Be
Question: One of our practitioners copies and pastes the same template in their notes over [...]

Podiatry Coding:
Know the Documentation Requirements for Anti-Fungal Treatments
Question: A patient presents to our podiatry practice with fungal nails, and the podiatrist pared [...]

Emergency Department Coding:
Know Stages to Take Pressure Off When Coding These Ulcers
Question: A patient reports to the emergency department (ED) with a pressure ulcer on their [...]

Otolaryngology Coding:
Peruse This Primer for Nasal Polyp Removal Coding Precision
And mind these modifiers to avoid denials. Nasal polyps are benign mucosal growths that can [...]

Cardiology Coding:
Check Your Coding Knowledge of Cardioplegia Medication in CABG Procedures
Question: A patient’s record includes the following documentation: Appropriate consent obtained; patient transferred to the [...]

Primary Care:
Learn When and How to Correctly Use Personal History Codes
Refresh your knowledge of the Z codes to accurately report past medical conditions that affect [...]

Diagnostic Radiology Coding:
Do Pelvic X-rays Receive a Separate Code When Captured With Hip X-rays?
Question: I have a radiology report where the physician documented, “An AP pelvis and lateral [...]

Emergency Department Coding:
Rely On Modifier Trio for This Elbow Fix
Question: A 4-year-old patient presents to the emergency department (ED) with an obviously displaced right [...]

Compliance:
Leverage the Payers’ Resources to Keep More of Your Claim Payment
Learn how to use each payers tools to your practice’s advantage. Although every practice prioritizes [...]

Urology Coding:
Prepare for New Prostate Procedure CPT® Codes in 2026
Get to know the new in-bore prostate biopsy codes. With 2026 approaching, urology coders will [...]

Pulmonology Coding:
Use R Codes to Report Unspecified Abnormal Findings
Question: One of our pulmonologists ordered a chest X-ray for a patient to evaluate their [...]

Podiatry Coding:
Tackle Turf Toe Injury Coding With These Tips – Part 2
Is there a specific turf toe treatment procedure code? Turf toe is a painful injury [...]

Neurology & Pain Management Coding:
Stay Awake to Routine EEG Coding Possibilities
Consider the patient’s consciousness status before selecting a code. When the provider performs an electroencephalogram [...]

Pediatric Coding:
Recent NCCI Edits Creating a Problem
Question: I just got a denial for a patient who received a nasal flu vaccine [...]

Medicare Regulations:
Find Out Which Proposals Made the MPFS Final Rule
The final conversion factors are lower than what CMS initially proposed. The Centers for Medicare [...]

Emergency Department Coding:
Navigate E/M Codes for Patients in the Emergency Department
Time is definitely NOT of the essence when it comes to ED coding. When a [...]

Otolaryngology Coding:
Know the Difference Between These Turbinate Surgery Codes
Question: What is the correct way to code the following op note? I am having [...]

Pediatric Coding:
Don’t Get Swallowed by Strep Test Coding
Question: I’m new to pediatric coding, and I’m unsure how to code the following encounter: [...]

Neurosurgery Coding:
Know Shunt Malfunction Types to Master Coding
Question: Encounter notes indicate that the neurosurgeon saw a patient who was experiencing headache, vision [...]

Practice Management:
Gain Confidence in Your Query Process
Question: We are trying to outline our query process and want some more insight. When [...]

Compliance:
Remain HIPAA Compliant While Transitioning to Digital
Question: I’m a manager at an office that still uses a lot of paper. We [...]

Optometry/Ophthalmology Coding:
Take These 4 Steps to Master Diabetic Retinopathy Dx Coding
Don’t forget to test yourself at the end. The most severe complications of diabetes are [...]

Pulmonology Coding:
Examine This Guide to Common Pulmonary Procedure Codes — Part 2
Learn how to report HSATs for Medicare patients. Pulmonary medicine encompasses a wide range of [...]

Ob-Gyn Coding:
Know What to Do When Induction Takes Days
Question: Do most payers cover evaluation and management (E/M) codes for patients who are scheduled [...]

Ob-Gyn Coding:
Keep Global Codes on Hand Even When MD Leaves
Question: One of our providers recently left our office, so all the patients were transferred [...]

Ob-Gyn Coding:
Dive Deep Into Hysteroscopy Coding With This Guide – Part 1
Why knowing when — and how — to report each code can be tricky. Hysteroscopy [...]

Otolaryngology Coding:
Bill for Grafts in This Tympanic Membrane Perforation Repair Encounter
Question: Our provider repaired a tympanic membrane perforation using both a tragal cartilage graft and [...]

Cardiology Coding:
Endovascular Revascularization Coding: How to Report a Superior Vena Cava Stent Procedure
Don’t confuse codes for veins with codes for arteries. When your provider performs a percutaneous [...]

ICD-10-CM Coding:
Use These Tips for Educating Providers on Diagnosis Documentation
When your provider’s documentation falls short, approach them with official guidelines and confidence. Sometimes an [...]

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