Advanced Search

Revenue Cycle Insider

Path/Lab Coding:

Understand Uncertain Does Not Mean Unspecified

Published on Tue Jul 28, 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

July 2026

Primary Care Coding:
Code Palpitations as a Symptom When Supported by Documentation
Question: A 19-year-old patient presents to a family medicine clinic reporting episodes of what they [...]

Anesthesia Coding:
Understand Why Physical Status Modifiers Are Useful, Even When Not Reimbursable
Some payers consider physical status just information, but they contextualize some anesthesia services. Coding and [...]

Diagnostic Radiology Coding:
Identify the Different Imaging Tests for Suspected Osteomyelitis
Find out which modality is considered the gold standard. One of the most challenging conditions [...]

Urology Coding:
Understand CPT® ESWL and Ureteroscopic Stone Treatment Coding
Do you need modifier 53 for an ESWL converted to surgical treatment? Urinary stone disease [...]

Pulmonology Coding:
Decipher Interstitial Lung Disease Diagnosis Coding
Learn how to identify the phases of ILD. Coding for interstitial lung disease (ILD) is [...]

Emergency Department Coding:
Get Your Facts Straight to Code FAST Exams
FAST vs. eFAST: Do you know the difference? A patient presents to the emergency department [...]

Cardiology Coding:
Document the Complete Clinical Picture Beyond Chest Pain
Consider these best practices for documenting diagnostic evaluations, supporting medical necessity, and improving coding accuracy. [...]

Neurology & Pain Management Coding:
Know Steps to Follow for Arthrocentesis Coding
Physician will start with E/M, imaging to decide if service is necessary. Arthrocentesis is a [...]

Diagnostic Radiology Coding:
Differentiate Between 93970 and 93971 for Suspected DVT
Question: A senior patient came into our radiology practice with left calf swelling, tenderness, warmth, [...]

Urology Coding:
Pinpoint the Correct Nephrolithotomy Procedure Code
Question: A 54-year-old patient presented to the emergency department (ED) with severe lower abdominal pain [...]

Medicare Regulations:
Find Modifier Clarity for Facet Joint Injection in LCD
Question: I know Medicare sets coverage limits on the number of therapeutic facet joint injections [...]

Compliance:
Be Proactive About Compliance to Reduce Chance of Fraud
Educating providers about others’ mistakes can emphasize the risk of upcoding. Upcoding, unbundling, and inaccurate [...]

Gastroenterology Coding:
Is 43239 Restricted to a Certain Number of Biopsies?
Question: I have a procedure note for an esophagogastroduodenoscopy (EGD) with a biopsy. The 45-year-old [...]

Pediatric Coding:
Get Ready for Back-to-School Visits With These FAQs
Strengthen your screening and immunization coding skills before the rush! This season brings a familiar [...]

Path/Lab Coding:
Understand Uncertain Does Not Mean Unspecified
Question: What does it mean when a pathologist describes a neoplasm of the breast as [...]

Path/Lab Coding:
Brace Yourself for Bad News in the 2027 MPFS
Big reductions in CDLT valuations are heading your way. Labs don’t have much to look [...]

Path/Lab Coding:
Know When to Bill for Cellular Enhancement When Examining Breast Aspiration
Question: Our pathologist performed a fine needle aspiration (FNA) on a patient’s breast, then examined [...]

Diagnostic Radiology Coding:
Learn Why a Head CT Without Contrast Is Needed in Emergency Situations
Question: A 65-year-old patient arrived at the emergency department (ED) claiming a sudden onset of [...]

Technology & Innovation in Healthcare:
Learn How RPM/RTM Reimbursement Rules Could Change in 2027
Also, CMS is seeking input on remote monitoring code adjustments. On July 16, 2026, the [...]

Optometry/Ophthalmology Coding:
Decode Visual Field Testing Codes With Confidence
Do VF testing codes apply to one or both eyes? Visual field (VF) testing, also [...]

Otolaryngology Coding:
Get the Answers to These 4 Frequently Asked Tonsillitis Questions
Also, remember to stay alert for these key coding considerations. Tonsillitis is probably one of [...]

Urology Coding:
Use Neoplasm Codes for Confirmed Pathology Results
Question: A patient presented to the urologist complaining of blood in their urine. After reviewing [...]

ICD-10-CM Coding:
Use an ‘Other’ Code to Best Capture African Tick Bite Fever
Question: I’m reading notes for a recent patient encounter. The patient presented with fever, headache, [...]

Neurosurgery Coding:
Get Treatment Types, Diagnoses Straight on Vertebral Fracture Repairs
Do you know the different fracture and treatment types? When your surgeon repairs a patient’s [...]

Orthopedic Coding:
Get Paid for Your Bankart and Synovectomy Claims
Don’t let 1 missing sentence lead to a denial. Shoulder arthroscopy procedures can present unique [...]

Neurology & Pain Management Coding:
Go to 6th Character for Epilepsy Diagnoses
Question: Encounter notes indicate that a patient suffers from “epilepsy w/grand mal on waking.” There [...]

Primary Care:
Document the Diagnostic Journey
Focus on capturing clinical reasoning in primary care. A patient presents with fatigue. Initial testing [...]

Cardiology Coding:
Know the True Meaning of ‘With’ in the ICD-10-CM Alphabetic Index
Question: I work for a cardiology office and reviewed a progress note for a patient [...]

Orthopedic Coding:
Step up to Code This Ankle Injury
Question: A patient who injured their left ankle after falling from a ladder reports to [...]

Otolaryngology Coding:
Get the Full Picture on Partial Thyroidectomy Coding
Question: A patient returned to our surgeon after previously having a thyroidectomy. The surgeon removed [...]

Podiatry Coding:
Don’t Stress About Coding This Foot Fracture Case
Question: A 30-year-old patient presented to the podiatrist with dorsal left foot pain that had [...]

Practice Management:
Prepare for Possible Reimbursement Redistribution in 2027
CMS is proposing making PE reimbursement more responsive to current market conditions. In the CY [...]

Medicare Regulations:
Beware of Possible, Big-Picture Changes to Medicare Eligibility for Some Individuals
Question: I’ve looked at the calendar year (CY) 2027 Medicare Physician Fee Schedule (MPFS) and [...]

Anesthesia Coding:
Sometimes You Can Bill for Anesthesiologist’s Time Despite Canceled Surgery
Question: I’m newer to anesthesia coding and need help with a canceled case. The surgery [...]

Neurology & Pain Management Coding:
Ace Autonomic Nerve Injection Encounters With These Codes
Question: If the physician performs an autonomic nerve injection of an anesthetic agent, is there [...]

Ob-Gyn Coding:
Use ‘0’ as the 7th Character With Single Gestation Maternal Complication Codes
Question: I’m new to ob-gyn coding and I’m having a lot of trouble understanding the [...]

Pulmonology Coding:
Identify the Correct Diagnosis Code for Idiopathic Pulmonary Fibrosis
Question: A 75-year-old new patient presented to the pulmonologist with chronic cough, fatigue, and weight [...]

Pulmonology Coding:
Can You Report Asthma With a COPD Exacerbation Case?
Question: Our pulmonologist saw a senior patient who was experiencing an exacerbation of their chronic [...]

Podiatry Coding:
Navigate Routine Foot Care Coverage Across the 7 MACs
Same procedure, 7 personalities — a field guide to Medicare podiatry billing. Routine foot care [...]

Oncology/Hematology Coding:
Take These 4 Steps for Accurate RETACRIT® Coding
Question: What is the correct way to bill for RETACRIT® for a patient undergoing erythropoiesis [...]

Ob-Gyn Coding:
Does Granulation Tissue Cauterization Fall Under Postpartum Care?
Question: A patient presented to their gynecologist with perineal irritation and urinary frequency. Six months [...]

Medicare Regulations:
Get a Glimpse of Future Payment Possibilities via CY 2027 MPFS
CMS is continuing with two CFs, but primary care may make out better than specialties. [...]

E/M Coding:
See How CMS Proposes to Reshape E/M Payments in 2027
CMS seems to move in opposite directions, but the changes all affect reimbursement more than [...]

General Coding:
CMS Proposing Changes to Advance Care Planning
Two new HCPCS codes could change how you bill ACP. The Centers for Medicare & [...]

In Case You Missed It (RCI Bonus Content):
Understand the Clover Health Ruling, Rethink Coding and Documentation in a Value-Based Care Environment
The ruling points to the need for proactive documentation. The Medicare Advantage (MA) Star Ratings [...]

E/M Coding:
Code Patient Portal Discussions With Virtual E/M Rules in Mind
Question: A provider asked me about possibly billing a lengthy patient portal exchange with an [...]

Anesthesia Coding:
Bill the OR Case, Not Just the Surgeon’s CPT® Code
Question: I’m newer to anesthesia coding and need help with an operating room (OR) case. [...]

Podiatry Coding:
Base Your Lesion Shaving Codes on Pre-Procedure Measurements
Question: A podiatrist shaved an epidermal lesion measuring 1.2 cm from a patient’s left foot. [...]

General Surgery Coding:
Use These 3 Tips to Guide Your Expert-Level Appendectomy Coding
Reporting complications and conversions just got easier, thanks to these key tips. Appendectomies can be [...]

Cardiology Coding:
Pin Down Heart Failure Specificity Before Choosing I50.-
Question: I’m reviewing a cardiology note for a 72-year-old established patient seen after an emergency [...]

ICD-10-CM Coding:
Rely on Reason for Visit if Allergy Tests Don’t Provoke Reaction
Question: I just started at an allergist’s office and sometimes we see patients who come [...]

Emergency Department Coding:
Learn How to Navigate SDOH Code Reporting
Question: I’m reviewing an emergency department (ED) visit where the provider documents that the patient [...]

Gastroenterology Coding:
Check out These 7 Steps to Coding Colonoscopies After Positive Fecal Results
Here’s how to use Medicare modifier PT. Colorectal cancer screening has changed significantly over the [...]

Otolaryngology Coding:
Don’t Let This Code Choice Strike the Wrong Nerve
Question: We recently got denied for billing 64450 with R05.3. Why is this, and what [...]

Pediatric Coding:
Confidently Code This Muscle Weakness Case
Question: A 10-year-old patient presents to outpatient physical therapy six weeks after sustaining a closed [...]

General Surgery Coding:
Look to Soft-Tissue Tumor Codes for a Lipoma Excision
Question: I have a surgical report that lists the procedure as an excision of a [...]

Ob-Gyn Coding:
Learn How to Sequence High-Risk OB and IVF Pregnancy Codes
Don’t assume every IVF pregnancy qualifies for an O09.81- code. Advances in reproductive medicine have [...]

Neurology & Pain Management Coding:
Look to Combo Codes on Some Evoked Potentials
Question: A 58-year-old presents with a year of progressive weakness and stiffness in both legs [...]

Oncology/Hematology Coding:
Know to Avoid Compliance Pitfalls and Support Accurate Cancer Dx Coding, Part 1
Look at these OIG audit results and learn. The Office of Inspector General (OIG) recently [...]

Primary Care Coding:
Evaluate MDM for Acute Symptoms With Tests Ordered
Question: An established 46-year-old patient presented to the primary care office reporting vomiting and diarrhea [...]

Emergency Department Coding:
Separate E/M From FBR Before Making Coding Decision
Question: A patient was working under their car when a fragment of metal fell from [...]

Neurosurgery Coding:
Be Sure to Code Only for Surgeon’s Services in ED Encounters
Question: A 73-year-old patient presents to the emergency department (ED) with a severe, sudden onset [...]

General Surgery Coding:
Hit the Target With Your Tendon Sheath Surgical Coding
Question: I’m having trouble choosing between 26055 and 26145 for a procedure. The patient presented [...]

Gastroenterology Coding:
Understand Why Waiting for Pathology Matters in Coding
Question: I read the Revenue Cycle Insider article, “Use These 5 Steps to Code [...]

Technology & Innovation in Healthcare:
Examine How Senior Citizens Can Use VR for OT and PT
Question: Are virtual reality (VR) therapies only beneficial to patients who are middle aged or [...]

Compliance:
Avoid Billing Mistakes in Multi-Location Practices
Question: If a patient receives an evaluation and management (E/M) service at one practice location and [...]

Compliance Coding:
Understand E/M Billing for Preoperative Visits
Question: Our surgeon saw a patient in the office, evaluated their condition, and scheduled surgery. [...]

Orthopedic Coding:
Don’t Overcode This Arthroplasty Procedure
Question: The practitioner’s notes show that a diagnostic arthroscopy of the right hip was performed. During [...]

Pediatric Coding:
See What a Difference a Day Makes
Question: When a physician provides critical care to a neonate, and the patient turns 29 days [...]

General Coding:
Apply MEAT to Support Chronic Condition Coding
Question: A Medicare Advantage patient presents for a routine follow-up visit. The provider documents type [...]

Optometry/Ophthalmology Coding:
Remember That an IOL Is an Implant
Question: Is there a separate code only for intraocular lens removal (IOL) or should we [...]

Technology & Innovation in Healthcare:
Watch Out for Copy-Forward and Imported Information
Question: After reading the Revenue Cycle Insider article, “Learn What You Can — and [...]

Oncology/Hematology Coding:
Look to Medicare Guidance for Breast Reduction Reimbursement
Question: One of our patients needs breast reduction to ensure breast symmetry following breast reconstruction [...]

Optometry/Ophthalmology Coding:
Don’t Forget a Cause Code for Burn Injuries
Question: I have a report for an encounter with a 12-year-old patient. The patient was [...]

General Coding:
Bill 96372 for Injection With Medication Supplied From Elsewhere
Question: Our office administers patient-supplied intramuscular medications. Can we report CPT® 96372 for the injection [...]

ICD-10-CM Coding:
Drug Toxicity Coding: Know When It’s an Adverse Effect, Poisoning, or Toxic Effect
Poisoning symptoms and adverse effects from proper use may look similar, but they require different [...]

Practice Management:
Revenue Cycle: Don’t Let Deductibles Drain Your Early-Year Cash Flow
Verify benefits, educate patients, and wait for the payer adjudication when the deductible amount is [...]

E/M Coding:
Look at All Elements of MDM, Not Just Symptoms
Question: An established patient presents with two days of sore throat, congestion, cough, fatigue, and [...]

View All

Subscribe to newsletter