decisionhealth Newsletters, Part B News - 2016 Issue 12 (December)
Does ‘shall’ mean ‘must’? In law, maybe – but not in CMS, CPT manuals
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Article Overview
This article explains a recurring interpretation issue in medical coding guidance: whether words like “shall” or “should” create mandatory billing or documentation requirements. It compares language used in CPT materials with Medicare documentation guidance and is aimed at coders, billers, compliance staff, and clinicians who work with evaluation and management documentation.
Why This Topic Matters
Understanding the difference between legal-style wording and coding guidance language affects documentation practices, billing workflow, and compliance review. The topic is especially relevant for professionals who rely on CPT and Medicare manuals for evaluation and management service reporting.
Article Sections
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Question
Introduces the interpretation issue being raised about how wording in official coding guidance should be understood.
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Answer
Summarizes commentary on how similar language is treated in coding references and documentation guidance, with references to CPT and Medicare materials.
What You Will Learn
- How official coding guidance may use language differently from statutory or regulatory text
- How CPT and Medicare documentation references are discussed in relation to evaluation and management services
- Why interpretation of guidance language can affect coding and documentation practices
- When it may be appropriate to seek clarification from a Medicare administrative contractor
Who Should Read This
- Medical coders
- Billers
- Compliance staff
- Physicians and clinical documentation staff
- Practice managers
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