Consult Documentation Guidelines

Categories:   Billing   Coding   Compliance   Documentation Guidelines   Medical Records   Medicare   Specialty Coding   Surgical Billing & Coding  

 

·         Medicare has made it very clear that consults CANNOT be shared between non-physician practitioners and physicians. If a non-physician practitioner performs any of the key elements of the consult, then the consult cannot be billed under the physician NPI. For commercial carriers, be sure and find out if these visits can be shared--don't just assume that they can.

·         Primary care or cardiology physicians who are asked to clear a patient for surgery can bill a consult code, even if the clearance is for an established patient. Remember that for Medicare patients, surgery clearance is only covered for patients with an underlying medical condition such as hypertension or diabetes that must be managed to safely perform surgery. Most carriers suggest the use of V72.83 diagnosis code for pre-operative surgery clearance. Remember that the requirements for written request from requesting physician and the need to send back your opinion to the requesting physician still apply.

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? 

Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.

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.

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.

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.

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

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),....