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Information Sharing with the Feds is Risky Business

by  David M. Glaser, Esq.

Over the last few weeks, a few articles of mine addressed interacting with government agents. One topic that I did not discuss was determining whether you can, should, or must share information with the government.  Unfortunately, it’s not possible to definitively answer that question for every topic, even in...

Government Shutdown Looming as Congress Dithers

by  Matthew Albright

Like most of the world, I procrastinate when paying my bills. I tend to put them off until the very last minute. And that pretty much explains Congress’s strategy last year – and they clearly plan on continuing this approach for 2024. The tough stuff, like funding a government,...

Artificial Intelligence in Healthcare - A Medical Coder's Perspective

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 

ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.

Changes to COVID-19 Vaccines Strike Again

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.

2024 CPT Coding Updates...Are You Ready?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Each year the CPT coding updates are published and coders nationwide rush to ensure they understand the impact they will have on their workflow and organization in general. For the first time in three years, changes to the Evaluation and Management (E/M) codes are minimal. However, the Medicine section, specifically the codes and guidelines for reporting COVID-19 vaccines have significant changes and unfortunately they are not reflected in that shiny, new CPT codebook you just purchased.

New ICD-10-CM Codes for Reporting Coronary Microvascular Dysfunction

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Women are more likely than men to be diagnosed with coronary microvascular dysfunction, a micro coronary artery vessel disease that has similar symptoms as coronary artery disease but no detectable coronary disease.

How Much Interaction Do Coders Have with Providers?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

How much interaction do you have with providers in your coding role? This question is interesting in that there are many coding jobs that require day-to-day interaction with providers and many others where the coder never interacts with physicians or nonphysician providers.

Updated ICD-10-CM Codes for Appendicitis

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.

Should I Report the Symptom or Confirmed Diagnoses for Testing?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Knowing when to report symptom codes has always been a conundrum for coders at one point or another in their career but with the complex EHRs and coding systems used today, requiring a diagnosis be submitted with every physician order for a lab test, image request, etc., it isn't a surprise that the question continues to pop up. So when is it appropriate to report symptom codes?

CMS Issues Final Rules for PFS, OPPS/ASCs

by  Mark Spivey

The regulatory changes will create a variety of changes for providers. Amid a flurry of regulatory activity, federal officials late last week issued twin final rules governing changes to the Medicare Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS), with the latter also featuring adjustments...

The Trouble with Cookies – and the Civil Liability They Can Present to Providers

by  Geoff Koslig

As a provider, a question worth asking yourself these days is this: what degree of risk is there that you might have something on your website that could lead to a multi-million-dollar class-action lawsuit and a determination by the U.S. Department of Health and Human Services (HHS) Office for...

COVID Vaccine Coding Changes as of November 1, 2023

by  Wyn Staheli, Director of Content - innoviHealth

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Adds Specialties for Behavioral Health Services

by  Wyn Staheli, Director of Content - innoviHealth

Questions and Answers for the changes CMS has made to Medicare Specialties for Behavioral Health Services.

Reviewing the Guidelines for Reporting ICD-10-CM Aftercare Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Understanding the appropriateness of reporting ICD-10-CM aftercare codes related to injuries, degenerative conditions, and postsurgical scenarios can be a bit confusing. Does the injury code suffice or should there be an aftercare code and a postsurgical code added? A quick review of some coding scenarios might help clear up the confusion.

Activity Related to the No Surprises Act Continues to Surprise, with No Slowdown in Sight

by  Adam Brenman

The Centers for Medicare & Medicaid Services (CMS) can’t seem to catch a break of late. 2023 has been a tough year for the agency, with the court system and Congress dealing it repeated blows, primarily over enactment of the No Surprises Act (NSA). Many are undoubtedly at least...

Reporting Evaluation & Management (E/M) Services with Wellness or Preventive Medicine Service Encounters

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Preventive medicine services, initial preventive physical examinations (IPPE), and the annual wellness exam consist of many required performance and documentation criteria to ensure ample patient history is obtained and charted in an effort to reduce the risk of disease and disease progression. Although not planned, these encounters often include a problem-oriented visit as well, requiring the coder to know how to separate out the preventive service from the problem-oriented encounter for coding and billing.

Medicare Guidance Changes for E/M Services

by  Wyn Staheli, Director of Content - innoviHealth

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.


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