Revenue Cycle Insider
Compliance:
Rely on These Resources for CDI Research
Published on Wed Jan 22, 2025
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
January 2025
- Orthopedic Coding:
Understand the Complexities of Shoulder Arthroplasty Coding
Know when to report arthroplasty revisions. Patients experiencing pain and stiffness in their shoulders might [...] - Urology Coding:
Code Incontinence Claims With Confidence
Add all relevant codes linked to the diagnosis to avoid denials. Coders must be meticulous [...] - Pulmonology Coding:
Prevent a Surfactant Administration Coding Collapse
Can you report 94610 with critical care codes? Find out. Babies who are born prematurely [...] - Pediatric Coding:
Find Differences Between Apnea Types
Question: When I see documentation that says a newborn patient has apnea, is it always [...] - General Surgery Coding:
Break Down the Differences Between ‘Excision’ and ‘Destruction’
Question: I have an operative note that states the surgeon “removed” a 1.6 cm basal [...] - Neurology & Pain Management Coding:
Alter EMG Coding When NCS Occurs
Resort to add-on codes for EMG in certain scenarios. When a patient reports to the [...] - Optometry/Ophthalmology Coding:
Are Strabismus Surgery Procedure Codes Bilateral?
Question: I have an operative note detailing an ophthalmologist’s strabismus surgical procedure on both eyes [...] - Optometry/Ophthalmology Coding:
Learn How to Report Monthly Hydrophilic Lens Renewals
Question: Which code should we use to report monthly toric contact lens replacements? Oklahoma Subscriber [...] - General Surgery Coding:
Skip the Breast Biopsy Codes for an Axillary Lymph Node Biopsy
Question: A patient presented for a superficial axillary lymph node core needle biopsy. The procedure [...] - Medicare Regulations:
Know Obligations in Case of Bankruptcy
Question: Does a medical practice have any obligations to Medicare or Medicare Administrative Contractors (MACs) [...] - General Coding:
Stay in Your Lane, Modifiers
Question: I’m new to medical coding and still don’t fully understand the role of modifiers; [...] - Gastroenterology Coding:
Find Out if You Can Report 45380 and 45385 Together
Question: I have the following documentation in an operative note: A single sessile 5 mm [...] - Gastroenterology Coding:
Use an Additional Code for This Chronic Ulcer Case
Question: A patient with a history of moderate alcohol dependence presented for a follow-up visit [...] - Diagnostic Radiology Coding:
Err on the Side of Symptoms When X-rays are Negative
Question: A patient presented to their primary care physician (PCP) with left shoulder pain that [...] - Neurosurgery Coding:
Put the Pieces Back Together to Accurately Code Skull Fractures, Repairs
It’s the small details that make or break an accurate diagnosis. Patients who suffer from [...] - Otolaryngology Coding:
Test Your Thyroidectomy Coding Skills With This Quiz
You may have your thyroidectomy work cut out for you. Question 1: What is the [...] - Diagnostic Radiology Coding:
Get to the Bottom of This Ankle Fracture Coding Case Study
Find out when ‘and’ means ‘or’ in diagnosis coding. Broken bones are one of the [...] - Diagnostic Radiology Coding:
Learn Which Code to Use for a Bone Fragment Diagnosis
Question: I have a radiology report that documents a “redemonstration of the distal ulnar fracture [...] - Practice Management:
Look for Reasons for Noncoverage Before Providing Services
Question: My practice performed a trigger point injection (TPI) and used ultrasound guidance for the [...] - General Surgery Coding:
Get Answers to Trach Coding FAQs
Know what separates tracheotomies and tracheostomies. Tracheotomies and tracheostomies are two procedures that often get [...] - Optometry/Ophthalmology Coding:
Clarify Your Cataract Extraction Coding Knowledge — Part 1
Understand reporting of simple, complex, and combined procedures. With age comes wisdom, experience, and for [...] - Emergency Department Coding:
Documentation Vital to Securing Critical Care Pay
Does your claim include a provider statement? Patients who report to the emergency department (ED) [...] - Primary Care Coding:
Understand How SDOH Affects Your Patients — and Your Bottom Line
Hint: Don’t forget comorbidities when you’re coding. As the first stop in many healthcare situations, [...] - Practice Management:
Don’t Miss This Patient Privacy Exception
Question: Can I release a patient’s balance over the phone or in person to someone [...] - Primary Care Coding:
Know Your Responsibilities for FMLA Certifications
Question: What information do we need to provide for a patient who’s seeking leave through [...] - Anesthesia Coding:
Consider Physical Status Exception
Question: A healthy patient with an uncomplicated seven-month pregnancy requires surgery for ankle surgery unrelated [...] - Gastroenterology Coding:
Learn How to Identify Intestinal Fistula Codes
Know the ins and outs of coding the conditions and treatments. As a gastroenterology coder, [...] - Primary Care Coding:
In Asthma Notes, Know Difference Between Extrinsic and Intrinsic
Question: I work at a family medicine practice and our providers see patients with asthma. [...] - Podiatry Coding:
Take the Right Steps to Footwear and Insole Coding Knowledge
Ace this quiz to keep your orthotic and specialty shoe skills sharp! Question 1 scenario: [...] - Technology & Innovation:
Direct Your AI Device Development With FDA Guidance
Question: Technology and artificial intelligence (AI) advance incredibly quickly, but have developers thought about what happens [...] - Oncology Coding:
Code This Chemo Infusion Administration Scenario
Don’t forget to pay attention to 2025 HCPCS deletions and revisions. Coding infusions is perhaps [...] - Otolaryngology Coding:
Look to Laterality to Bill Concha Bullosa Services Correctly
Question: What is the CPTÒ code for this? This is all that is documented: “Using [...] - Compliance:
Bolster Continuity of Care Through Documentation
Question: I feel like providers are grateful for billers and coders for sorting through so [...] - Technology & Innovation:
Monitor Senior Patients in Rural Locations
Question: We have several senior patients who live in rural areas far from our clinic. [...] - Compliance:
Rely on These Resources for CDI Research
Question: Which resources are useful in the daily workflow of clinical documentation integrity (CDI) specialists? [...] - Cardiology Coding:
Use This Trick to Distinguish Rheumatic From Non-Rheumatic Valve Disease
Question: How do I know when to report a diagnosis code for valve disease that [...] - Medicare Regulations:
Use an Additional Code for ACP Conversation
Question: My provider is conducting conversations about advance care planning (ACP) during annual wellness visits [...] - Cardiology Coding:
When Reporting Revascularization, Don’t Code These Steps Separately
Question: My provider takes really specific notes during revascularization procedures, and I’m not sure whether [...] - Emergency Department Coding:
EMTALA Means No Patient Left Behind
Question: I am relatively new to emergency department (ED) coding, and I’ve heard a few [...] - Otolaryngology Coding:
Let Documentation Determine Correct Repeat Service Modifier
Question: Five days after draining a peritonsillar abscess, our otolaryngologist had to drain it a second [...] - Urology Coding:
Avoid Coding Surgeon-Induced Injuries
Question: A patient was scheduled to receive a penile prosthesis. However, because of a urethral [...] - Emergency Department Coding:
Keep SCAT5 Coding in E/M Realm
Question: Encounter notes indicate that a patient presented to the emergency department (ED) after being [...] - E/M Coding:
Focus on Date for Problems Addressed, Unaddressed
Question: When I’m looking at a patient’s medical record, how do I know whether the [...] - Path/Lab Coding:
Note This MUE to Bill Antibody Stains Correctly
Question: Our lab is having issues billing for 88341, 88342, and 88360. Fairly regularly, we [...] - ICD-10-CM Coding:
Code This Slippery Subsequent Scenario
Question: A patient came to our office after visiting the emergency department (ED) where they had [...] - ICD-10-CM Coding:
Refresh Your Knowledge on Diagnosis Coding for Substance Abuse and Behavioral Health
Do you know how to accurately use the F10.- to F19.- code range? The 10th [...] - Pediatric Coding:
Code Umbilical Granuloma Scenario With Confidence
Question: Our pediatrician saw a 6-day-old baby for the first time and diagnosed an umbilical [...] - Neurosurgery Coding:
Aspirin Use Could Lead to This Condition in Younger Patients
Question: A 15-year-old patient reports to the neurosurgeon’s practice with complaints of confusion and seizures [...] - E/M Coding:
Keep These Tips in Mind When Leveling Time
Question: Which aspects of a provider’s services count for time when leveling evaluation and management [...] - Pediatric Coding:
Identify These Common Rashes in Pediatric Patients
Hint: Some rashes may be specific to newborns. Pediatric rashes can develop for various reasons [...] - Oncology/Hematology Coding:
Don’t Get Left in the Dark by Dx Documentation
Question: One of our physicians is not putting diagnoses on their on-treatment visit (OTV) note. [...] - Podiatry Coding:
Avoid This Metatarsal Modifier Mishap
Question: What is the correct laterality modifier to bill with 28122? I first billed it with [...] - Anesthesia Coding:
Dive Deep Into Anesthesia Modifier Hows and Whys
Hint: Modifiers can show payers which anesthesia professional performed a service. Getting paid correctly with [...] - General Coding:
Look to G0317 for Nursing Facility Prolonged Service Codes
Hint: Time spent on services the day before and after the visit may count. Sometimes [...] - Oncology/Hematology Coding:
Look to History When Coding This Breast Symmetry Encounter
Question: In 2019, a patient had a bilateral mastectomy and bilateral breast reconstruction. The patient [...] - Urology Coding:
Traverse This Transvaginal Procedure
Question: My urologist recorded a laparoscopic transvaginal correction of a urinary bladder tear. I was originally [...] - Podiatry Coding:
Code This Ruptured Achilles Repair
Question: The surgeon’s notes indicate that a patient was seen due to a ruptured right Achilles [...] - Path/Lab Coding:
Get a Quick Look at These 2025 Path/Lab NCCI, MUEs, and PLA Code Updates
Don't miss these two increases to Medicare MUEs. Want to get your 2025 off to [...] - General Coding:
Understand When to Append Modifier 62
Question: I’m new to coding. When is it appropriate to append modifier 62? RCI Subscriber Answer: Modifier [...] - Path/Lab Coding:
Be Direct, Bill for Both These Bilirubin Tests
Question: If our lab performs both a total bilirubin and a direct bilirubin test, can [...] - ICD-10-CM Coding:
How Do I Determine the Duration for Acute vs. Chronic Conditions?
Question: I’m new to coding and am having trouble finding information as to when I should [...] - Neurology & Pain Management Coding:
Ask Doc for Sleep Apnea Details
Question: When a patient suffers from sleep apnea, how do I choose the correct ICD-10-CM [...] - Neurosurgery Coding:
Craniotomy Isn’t Always Separately Reportable With Skull Insertions
Question: The surgeon inserted a skull-mounted cranial neurostimulator pulse generator in a patient with vascular [...] - Neurology & Pain Management Coding:
Note These IQ Level Ranges for Intellectual Disability Dx
Question: The neurologist treats a patient with an intellectual disability. Encounter notes indicate that the [...] - Medicare Regulations:
Pocket These Tips for Categorizing Medicare and VA Claims Correctly
Don’t let confusion about where to submit a government payer claim derail your reimbursement. Last [...] - Cardiology Coding:
Identify 3 Common Devices Your Cardiologist May Use
Hint: ICDs treat ventricular tachycardia. Sharon Jane Oliver, CPC, CDEO, CPMA, CRC, discussed various devices [...] - Ob-Gyn Coding:
Master Medicare’s ‘Carve Out’ Rule
This modifier tells Medicare that the service isn’t covered. If you need to estimate what [...] - Orthopedic Coding:
Finger or Fingers? It Doesn’t Matter With This Dx
Question: If a patient has stress fractures in multiple fingers, would you report an ICD-10-CM [...] - Pulmonology Coding:
Break Down the Established Patient Definition
Question: We bill for a multispecialty clinic, which has a cardiothoracic surgeon, a cardiologist, and [...] - Anesthesia Coding:
Find Out if Epidural Catheter Placement Timing Matters
Question: If an epidural catheter is inserted with the intention of providing postoperative pain management, [...] - Technology & Innovation in Healthcare:
Deliver Healthcare to Patients in Other Countries Via Telehealth
Remember to obtain consent. Telehealth’s popularity in recent years has allowed healthcare providers to deliver [...] - Orthopedic Coding:
Consider Alternate Terms For This Synovitis Dx
Question: Encounter notes indicate that the surgeon treated a patient with “synovitis, toxic/wrist.” I cannot [...] - Ob-Gyn Coding:
Rh-Negative Status: What Dx Code Should I Use?
Question: What is the most accurate diagnosis code for Rh-negative status during pregnancy? Arkansas Subscriber [...] - Pulmonology Coding:
Report Nebulizer Demonstration and Treatment Together
Question: A pulmonologist performed a nebulizer treatment for a patient’s asthma and demonstrated how to [...] - Ob-Gyn Coding:
Untangle Modifiers 25, 57 With This Advice
Question: My ob-gyn decided a patient needed surgery, but I’m confused whether to report modifier [...] - E/M Coding:
Understand the Importance of History Documentation for E/M Coding
Remember the eight components of HPI when you’re looking at documentation. Since the evaluation and [...] - Compliance:
Know Your Rights and Responsibilities in Possible Healthcare Fraud Cases
Honesty really is the best policy. Government enforcement efforts under the False Claims Act are [...] - Practice Management:
Negotiate Your Payer Contracts With Confidence
Think about why your practice deserves a raise. “Most people will take ‘no’ for an [...]
View All
