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Primary Care Coding:

Perfect Your Coding When Physicians See Patients in Nursing Homes, Hospice

Published on Thu Apr 17, 2025

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Other Articles of

April 2025

In Case You Missed It (RCI Bonus Content):
Know How to Code Surgical Teams Correctly
Know when to use the co-surgeon, assistant-at-surgery, and surgical team modifiers. Over the last few [...]

Otolaryngology Coding:
Take This Advice for Foolproof Rhinoplasty Claims
Let these 2 Medicare LCDs be your guides. If your otolaryngologist performs a rhinoplasty, you [...]

General Surgery Coding:
Test Your Knowledge of Colorectal Procedure Coding
Query the provider before choosing an unspecified code. It’s essential to thoroughly examine the medical [...]

Neurosurgery Coding:
Remember, Laminectomy Removes the Entire Lamina
Question: What is the difference between a laminectomy and a hemilaminectomy, and which CPT® codes [...]

Neurosurgery Coding:
Use This Code for Brain Abscess
Question: Encounter notes indicate that a patient suffers from “embolic abscess, parietal lobe.” What is [...]

Neurosurgery Coding:
Stay on Coding Cutting Edge With SRS, Neuroendoscopy Smarts
See how these techniques have changed neurosurgery. Over the years, we have witnessed remarkable innovations [...]

ICD-10-CM Coding:
Follow These Principles for Coding the Principal Diagnosis
Hint: Use coding conventions as your North Star. While selecting a principal diagnosis sounds easy [...]

Compliance:
Stay Out of Hot Water by Disposing of PHI Properly
Training seasonal and permanent staff will avoid an audit. As summer approaches, many practices are [...]

Gastroenterology Coding:
Refresh Your Knowledge of Gallstone Codes
Do you know the appropriate diagnosis codes for gallstones and related procedures? While many patients [...]

Podiatry Coding:
Examine 5 Common Pediatric Podiatry Conditions
Find out what condition feels like stepping on a pebble. Between sports, playing, and growing, [...]

Cardiology Coding:
Differentiate These New ASCVD Codes
Question: What’s the difference between codes G0537 and G0538? I think they became billable in [...]

Emergency Department Coding:
Pull Correct FBR Claims Each Time With This Advice
Do you know when an ED E/M becomes an FBR? It’s spring again, which means [...]

General Coding:
Look to Status to Determine POS
Question: One of our providers is a surgeon who sometimes gets called to the hospital [...]

Medicare Regulations:
Look for These Forms for Credentialing Adjustments
Question: I need to make an adjustment to the credentialing information for one of my [...]

General Coding:
Navigate New Era of Coding With This Foundation
Hint: Documentation may matter more than ever. While the future of coding may seem scary [...]

Neurology & Pain Management Coding:
Lean on Add-On Code for Multiple RFAs
Question: Encounter notes indicate that the pain management (PM) specialist performed radiofrequency ablation (RFA) on [...]

Cardiology Coding:
Understand These Differences in Wearable Cardiovascular Devices
Hint: Some devices record continuously, but some need to be activated. Patients who may have [...]

Urology Coding:
Query the Provider to Avoid Uroflowmetry Confusion
Question: A uroflowmetry test was conducted in our clinic and the urologist noted, “lower urinary [...]

Neurology & Pain Management Coding:
Master Brain Anatomy, Symptoms for Simpler Stroke Dx Coding
Do you know how to score a stroke? “A stroke is an interruption of the [...]

Neurology & Pain Management Coding:
Look for Dominant Element When Choosing ADHD Dx
Question: Encounter notes indicate that the patient suffers from attention deficit hyperactivity disorder (ADHD); the [...]

General Coding:
Use PA-Specific Modifier to Report Their Services
Question: A physician assistant (PA) assisted one of our surgeons during a surgery. The provider [...]

Anesthesia Coding:
Don’t Count on Billing Inactive Interval Time
Question: A patient had surgery for cataract extraction and required monitored anesthesia care via a [...]

Medicare Regulations:
Find Clarity on Global Surgery Inclusion
Question: A patient who’s a Medicare beneficiary had surgery. They were in a lot of [...]

Compliance:
Sharing Credentials May Mean Breaking the Law
Question: We recently signed on a new physician at our practice and they’re only contracted [...]

Podiatry Coding:
Evaluate This EDL Tendon Transfer Case
Question: I am new to podiatry coding and need help reporting this procedure. The surgeon [...]

E/M Coding:
Understand What Services Are Included in Debridement Procedure
Question: A patient comes in for a wound debridement appointment every week. According to their [...]

Podiatry Coding:
Find Out if Osteotomies Are Included in a Subtalar Joint Fusion
Question: The podiatrist performed a subtalar joint fusion with rigid internal fixation, a medial calcaneal [...]

Practice Management:
Find Relief for Challenging Patient Situations
Modulating your own body language and tone can go a long way in de-escalating tension. [...]

Urology Coding:
Break Through These FAQs of Kidney Stone Coding
Lasering in on the location can help you choose the correct code. Coding for stones [...]

Gastroenterology Coding:
Learn How to Code High-Risk Screening Colonoscopies
Question: We had a Medicare patient come in for a colorectal cancer screening. What constitutes [...]

Oncology/Hematology Coding:
Get to the Point With This GIST Coding Guidance
Question: What is a gastrointestinal stromal tumor (GIST), and how is it coded? New Jersey [...]

Oncology/Hematology Coding:
Understand TNM Staging to Improve Dx Specificity
Let provider ocumentation guide you to the correct number of codes. As an oncology coder, [...]

Cardiology Coding:
Know What to Report for This Pacemaker Procedure
Question: What’s the best code to report a procedure involving a right ventricular permanent leadless [...]

Gastroenterology Coding:
Pinpoint the Correct Pancolitis Ulcerative Colitis Code
Question: I have a colonoscopy report where the physician describes the findings as: “Pancolitis ulcerative [...]

General Surgery Coding:
Identify Site for Hernia Repair With Gallbladder Removal
Question: The surgeon performed a laparoscopic gallbladder removal for a 42-year-old patient. During the same session, [...]

Orthopedic Coding:
Pick the Right Code for Your Pre-Auth Request
Question: I’m seeking a pre-authorization for a surgical procedure, and I need help finding the [...]

Orthopedic Coding:
Learn When to Report an OR Return Separately
Question: An orthopedic surgeon performed an open fracture treatment of the femoral shaft without placing [...]

Compliance:
Signatures Are Key to Proving Validity
Question: I was told that providers had to sign off on the encounters before creating/submitting [...]

Optometry/Ophthalmology Coding:
Crack the Code on This Damaged IOL Insertion Case
Question: I have a surgical report in which the surgeon performed cataract surgery. The surgeon [...]

Path/Lab Coding:
Understand These 2 LCDs Before Coding This Respiratory Pathogen Panel
Question: What is the correct way to bill for COVID, influenza A and B, and [...]

Primary Care Coding:
Perfect Your Coding When Physicians See Patients in Nursing Homes, Hospice
Plus: Nail down the right SNF visit codes. When your primary care provider sees patients [...]

Primary Care Coding:
Some Specificity Needed for Alcohol Use Reporting
Question: My practitioner recently documented “occasional alcohol use” in the social history section of a patient’s [...]

Primary Care Coding:
Use the Index to Correctly Code This Ataxia With Stroke Case
Question: During a patient’s annual wellness exam, my provider documented “ataxia with history of stroke.” [...]

Optometry/Ophthalmology Coding:
Identify the Code for Eyelid Retraction Injections
Question: A patient presented with complaints of chronic bilateral upper lid cicatricial retraction with lagophthalmos. [...]

E/M Coding:
Use These Strategies to Educate Providers, Part 1
Feel confident that you have knowledge to offer. Coders may have nightmares about the awkwardness [...]

Emergency Department Coding:
Check for Guidance Before Reporting Elbow Injection
Question: A 42-year-old patient presented to the emergency department (ED) with left elbow pain and swelling [...]

Emergency Department Coding:
Constant Worry Could Be Generalized Anxiety Disorder
Question: If a patient has a diagnosis of “overanxious disorder,” what is the appropriate ICD-10-CM [...]

Pulmonology Coding:
Build Your Pulmonary Hypertension Coding Knowledge
Learn what separates the pulmonary hypertension codes. Pulmonary hypertension (PH) can be defined as high [...]

Technology & Innovation:
Provide In-Home Pediatric Hospital Care
Question: Many families have asked about at-home hospital services for their young children. We have [...]

Diagnostic Radiology Coding:
Risks Are Too High to Gamble With Radiology Revenue
With radiology claims under tighter OIG scrutiny, compliance is always your safest bet. Radiology has [...]

Diagnostic Radiology Coding:
Solve This Sinus Tract Coding Question
Question: A patient presented to a radiology practice with complaints of chronic sinusitis. The patient’s [...]

Medicare Regulations :
Attention: Medicare Patient Appeal Changes Are Here!
Select inpatient to observation patient status changes can be scrutinized now, and even as far [...]

Practice Management:
Try This Networking Tip to Boost Referrals
Question: I work for a specialty practice, and our providers are hoping to boost their [...]

Pediatric Coding:
Know the Dos and Don’ts of Type 1 Diabetes Coding
Make sure you add these 2025 ICD-10 code updates to your list. There’s a lot [...]

Ob-Gyn Coding:
Knot in the Umbilical Cord: Do You Know What to Do?
Question: We had a patient come in with a knot in the umbilical cord. We [...]

Pulmonology Coding:
Are Patients New or Established When a Provider Changes Practices?
Question: I code for a pulmonologist who recently made the move from a private clinic [...]

Oncology Coding:
Find the Key to This Immunotherapy Encounter
Question: What is the correct primary diagnosis code for Keytruda? Should I use Z51.11 or Z51.12? Also, [...]

Technology & Innovation:
Use Health Data Statistics to Drive Decisions in Healthcare
Learn how margin of error and CIs affect the interpretation of results. From patient admission [...]

Otolaryngology Coding:
Avoid Integumentary Code for This Ear Lesion Removal
Question: Our otolaryngologist excised an ear canal lesion from a patient’s left ear. The op [...]

Technology & Innovation:
Coordinate With Chatbots to Improve Patient Happiness
Question: Like many healthcare practices, there are times when we see more patients than usual, [...]

Pulmonology Coding:
Report Noninvasive Oxygenation Assessments With a Category III Code
Question: I have a procedure report that lists the service performed as “noninvasive assessment of [...]

Diagnostic Radiology Coding:
Can You Report Phone Calls to Discuss Test Results?
Question: A patient presented for a dual-energy X-ray absorptiometry (DEXA) scan of their axial skeleton. [...]

Otolaryngology Coding:
Understand the Difference Between Caloric Vestibular Tests
Question: In a recent note on a patient who came in for vestibular testing following [...]

Path/Lab Coding:
Stay on Top of April Updates for Path/Lab MUEs, Fees, and ICD-10-CM
Plus, see what’s in store for PLA changes in July. The second quarter of 2025 [...]

Urology Coding:
Purpose of the PSA Test Will Determine Proper Coding
Question: An elderly patient was complaining of frequent urination during their annual exam. They also mentioned [...]

Pediatric Coding:
Remember This Nosebleed Treatment Coding Tip
Question: A patient presented bleeding from both nostrils and received treatment. Are nosebleed treatment codes [...]

Practice Management:
Shout About Language Facility
Question: Some of our providers are bilingual or multilingual. How can I let patients and [...]

E/M Coding:
Don’t Count on Reimbursement for Nonphysician EMR Adjustments
Question: If a clinical staff member or scribe makes entries into a patient’s medical record, [...]

ICD-10-CM Coding:
Understand ‘Unspecified Behavior’ Traits for Neoplasm Diagnosis
Question: A patient’s medical record says they have cancer of the neck, but the pathologist’s [...]

Anesthesia Coding:
Bust These Reimbursement Myths
Find clarity on how teaching anesthesiologists should be paid. Whoever said knowledge is power perhaps [...]

Ob-Gyn Coding:
How to Code a Lesion Incision and Removal
Question: I'm struggling with how to code this procedure: From the op note: 2x1 cm [...]

General Surgery Coding:
Purpose of Fat Transfer Determines Proper Code Choice
Question: Our general surgeon performed a revision of a reconstructed breast. The surgeon used a [...]

Pediatric Coding:
Follow These Steps for Coding Cellulitis Encounter
Question: An established 8-year-old patient presents with a slight fever and a red, blistered area [...]

Optometry/Ophthalmology Coding:
Thrive Under Pressure While Coding Glaucoma Treatments — Part 2
Find out if traditional or MIGS surgeries are more common. In the first part of [...]

Anesthesia Coding:
Account for ‘Time’ Based on These Moments
Question: How do I know when to start “counting” for time for anesthesia services? Florida [...]

ICD-10-CM Coding:
Take Heed of Patient’s Fancies
Question: A patient arrived at our emergency department (ED) presenting with pain while breathing, a dry [...]

Orthopedic Coding:
Unravel the Complexities of Coding Carpal Tunnel Syndrome — Part 2
Remember the ICD-10-CM 5th character specifies laterality. Carpal tunnel syndrome (CTS) occurs when the tunnel [...]

Ob-Gyn Coding:
True or False: Adhesiolysis Can Be Separately Reimbursed — Find Out
The key term is “extensive.” Some medical coders think lysis of adhesions codes are impossible [...]

Path/Lab Coding:
Go the Distance, Understand Specimen Collection Travel Allowance Codes
Question: We are a primary care practice with a traveling phlebotomist and our own lab, [...]

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