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Primary Care Coding:

Report E/M and Signs and Symptoms, Too

Published on Fri Feb 20, 2026

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February 2026

Otolaryngology Coding:
Note the Ins and Outs of PE Tube Procedures
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General Surgery Coding:
Cut the Confusion From Thyroidectomies
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Podiatry Coding:
Learn Key Strategies to Help Get Your Foot Neuroma Claims Approved
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Cardiology Coding:
Report Certain Deficits With Specific Dx Codes
Question: A cardiologist documented that a patient has cognitive deficits after and due to a [...]

Cardiology Coding:
Gather More Information for Correct ECMO Cannula Replacement Coding
Question: A provider documents replacement of an extracorporeal membrane oxygenation (ECMO) cannula but doesn’t specify [...]

Urology Coding:
Are These Urology Coding Pitfalls Putting Your Payments in Peril?
Find out if you’re using pre- and post-op modifiers correctly. Accurate coding in urology is [...]

Anesthesia Coding:
Check Imaging Used Before Selecting Injection Code
Question: A provider used ultrasound guidance when performing an injection in the zygapophyseal joint. Is [...]

Technology & Innovation in Healthcare:
Unlock Access to Wearable Devices Through New CMS and FDA Programs
Learn how innovative programs will speed up device integration. According to the Centers for Disease [...]

Neurosurgery Coding:
Nail the Approach and Anatomy Details for Vertebral Excision Coding
Anterior or posterior? Your coding depends on the answer. Patients who report to the neurosurgeon [...]

Pulmonology Coding:
Does Uncertain Behavior Mean the Same as Unspecified?
Question: I have an encounter note from a visit with a 50-year-old patient who presented [...]

General Surgery Coding:
Snip the Confusion From This Tonsillitis Case
Question: An 11-year-old patient with a history of tonsillitis presented to our department with a [...]

Technology & Innovation in Healthcare:
Receive Guidance on Managing Privacy and Consent
Question: I understand that interoperability and data sharing is important to providing healthcare to patients [...]

Neurology & Pain Management Coding:
Stay Sharp to Nail the Right Sacroiliac Joint Treatment Code
PM specialist could perform several services to treat these injuries. A common complaint by patients [...]

Compliance:
Watch Out for This Pre-Charting Risk
Question: What can I say to my providers to help them understand the risks of [...]

ICD-10-CM Coding:
Catch the Correct Code for Cleft Palate Imaging
Question: A pregnant patient was seen by a neonatologist due to the fetus having a [...]

E/M Coding:
Make MDM Documentation More Provider-Friendly With These Expert Tips
Hint: If you’re going to use a template, check it for accuracy. The 2021 changes [...]

Path/Lab Coding:
Understand These 2 Scenarios, Receive Pap Claim Pay
Question: The lab performed a liquid-based Pap test that the physician ordered, which we billed [...]

Pulmonology Coding:
Remember to Consider Face-to-Face Services for New/Established Patient Status
Question: A patient came into our pulmonology practice for a pulmonary function test (PFT) in [...]

Podiatry Coding:
Nail Down Nerve Conduction Studies Coding
Question: A patient presented to a podiatry clinic with complaints of persistent numbness and tingling [...]

General Coding:
Use This Tip When Reporting Bilateral Procedure
Question: A patient came in with lacerations on both eyelids. Do I need to use [...]

Compliance:
Bolster Your Compliance With a Global Approach
Don’t focus so much on billing and coding that you miss compliance weak spots elsewhere. [...]

Otolaryngology Coding:
Look to CPT Definitions, Descriptors for FBR Guidance
Take note of these documentation best practices. Foreign body removals (FBRs) are commonly performed in [...]

Optometry/Ophthalmology Coding:
Ace Your Corneal Transplant Coding With These Guidelines
Find out the differences between DSEK, DMEK, and DALK. Corneal transplantation has evolved dramatically over [...]

Optometry/Ophthalmology Coding:
Look to H43.8- to Code a Vitreous Detachment Diagnosis
Question: A 65-year-old new patient presented with floaters in their vision. The optometrist performed a [...]

Urology Coding:
Straighten Out How to Code Testicular Torsion
Question: I have a report where a patient presented to the emergency department (ED) with [...]

Neurology & Pain Management Coding:
Choose Single Code for These Paralysis Patients
Question: Encounter notes indicate that a patient suffers from sudden, unexplained muscle paralysis in the [...]

Orthopedic Coding:
Pinpoint the Correct Codes for Pediatric Orthopedic Cases
Find out how to code limb length discrepancies. Pediatric orthopedic surgeons represent a small segment [...]

Path/Lab Coding:
Know Payer Preference for Coding Multiple Units on Same DOS
Question: Our pathologist received and examined three separately identified skin lesion specimens from different body [...]

Neurosurgery:
Suture Count Matters When Choosing Correct Craniectomy Code
Question: The neurosurgeon is treating a 6-month-old patient with non-deformational dolichocephaly who needs a craniectomy [...]

Medicare Regulations:
Get Ready for the New Medicare Claim Edit for Hospice Patients
Question: Our manager talked to clinical and office staff about proper application of condition code [...]

Optometry/Ophthalmology Coding:
Do All Cataract Surgeries Mean a High Level of MDM?
Question: During a recent visit with an established patient, the ophthalmologist explained that the severity [...]

Podiatry Coding:
Cut Away Callus Removal Confusion
Question: I have an encounter note for a patient who presented with a painful callus [...]

Technology & Innovation in Healthcare:
Be Transparent With Patients When Asking About AI Use in the Exam Room
Question: Do you have any tips on how to handle getting patient consent for the [...]

General Coding:
Use These Codes When Your Patient Phones From Home
Question: Which codes are appropriate to use for audio-only medical phone encounters? AAPC Forum Participant [...]

Primary Care Coding:
Report E/M and Signs and Symptoms, Too
Question: A patient’s medical chart says that the provider spent 20 minutes in a telehealth [...]

Urology Coding:
Are Cognitive MRI Fusion Biopsies Reported With MRI Fusion Codes?
Question: Some of our urologists perform a cognitive MRI fusion transrectal or transperineal prostate biopsy. [...]

Orthopedic Coding:
Relieve the Pain of Coding This Bunion Removal Case
Question: A patient presented to the orthopedic practice with pain and deformity in the right [...]

Ob-Gyn Coding:
Is 76815 or 76816 Appropriate for a 36-Week Growth Scan?
Question: A patient pregnant at 36 weeks came into our ob-gyn practice for a growth [...]

In Case You Missed It (RCI Bonus Content):
Demystify Prorating in Obstetrics
Use this handy, practical guide for medical coders. One of the most common tasks in [...]

General Coding:
Questioning Your Grasp on Queries? Look to This Advice
When querying the practitioner, be aware not only of your tone, but of their time. [...]

Diagnostic Radiology Coding:
Use 72081-72084 to Report Scoliosis Evaluation X-rays
Question: A patient presented for a scoliosis evaluation, and their physician ordered cervical, thoracic, and [...]

Emergency Department Coding:
Take 3 Steps to Accurately Report Shoulder Injury Care in the ED
Hint: Modifiers will be key for collecting maximum pay for your services. Shoulder injuries are [...]

Primary Care Coding:
Consider Symptoms vs. Screening When Coding STIs
Don’t forget to consider prolonged service codes when warranted. When a patient is diagnosed with [...]

Pediatric Coding:
Don’t Be Stumped by This Bumpy Visit
Question: I have an pediatrician that wants to charge for the evaluation and management (E/M) [...]

E/M Coding:
Don’t Bill This Suture Removal Scenario as Incident-To
Question: A nurse practitioner (NP) at my practice removed sutures from a patient who received [...]

Practice Management:
Know How to Manage Employees Who Exceed Their Allotted Sick Days
Question: One of our employees has already used all of their allotted sick days but [...]

Emergency Department Coding:
Don’t Short Yourself Deserved Pay for This Splint Placement
Question: A patient reports to the emergency department (ED) complaining of severe pain in their [...]

Orthopedic Coding:
Do You Need an E/M Code for an Injection Procedure?
Question: I have a report for an encounter where an established patient presented for a [...]

Neurosurgery Coding:
Roll Some Tests Into E/M When Checking for Sciatica
Question: A new patient reports to the neurosurgeon complaining of pain in their left leg, [...]

Path/Lab Coding:
Get Up to Speed With the 2026 Category 1 and PLA Code Changes
Also, gain valuable insights into CLFS payments. In January, path/lab coders saw updates to both [...]

Primary Care Coding:
Find Clarity Coding This Perioral Dermatitis Encounter
Question: The notes for a primary care encounter say: Patient scheduled an appointment with their [...]

E/M Coding:
Rely on E/M to Report This Physical Exam Component
Question: A provider in my office examined a patient with male anatomy worried about a [...]

Gastroenterology Coding:
Find Out When to Use a History of UC Code
Question: When can ulcerative colitis (UC) in remission be called history of UC? Does the [...]

Gastroenterology Coding:
Pinpoint the Correct EGD Code for This Gastritis Case
Question: I have an op note for a diagnostic esophagogastroduodenoscopy (EGD) procedure. The patient presented [...]

Diagnostic Radiology Coding:
Can You Report Technical and Professional Components on Different Dates of Service?
Question: What date of service (DOS) should we use for billing the professional component of [...]

Practice Management:
Make Sure Staff Use Their Individual Logins
Question: I work for an independent practice that is being purchased by a larger organization. [...]

Compliance:
Look to Location-Specific Guidance for These Documentation Attestations
Question: How much time does a physician have to make an attestation for documentation that [...]

Pediatric Coding:
Use These New Immunization Counseling Codes in Your Practice, Part 2
Documentation will be key to new code reimbursement. Last month, Revenue Cycle Insider discussed in detail three [...]

Ob-Gyn Coding:
Learn How to Code a Repeat Pap Smear Plus UTI Evaluation
Question: A Medicare patient who is high risk due to their sexual behavior came in [...]

Medicare Regulations:
Don’t Use Q6 for Global Services or Fees
Question: I work for a surgical practice, and one of our providers is going out [...]

Gastroenterology Coding:
Learn 9 Tips for Demystifying Cirrhosis Coding
Pay attention to whether the cirrhosis is specified and whether complications are present. Struggling to navigate the tangled [...]

Oncology/Hematology Coding:
Take These 3 Steps to Determine Correct Lesion Removal Code
Question: A post-mastectomy patient with a diagnosis of invasive ductal carcinoma, coded to C50.911, went [...]

Emergency Department Coding:
Do Extra Leg Work for This Unspecified Dx
Question: Encounter notes indicate that a patient suffers from an acute embolism in their right [...]

ICD-10-CM Coding:
Back to ICD-10-CM Basics: Every Fundamental That Coders Need to Know
Whether you’re new to coding or you’re a seasoned professional, mastering the basics of ICD-10-CM [...]

Oncology/Hematology Coding:
Know When to Tie Receptor Status Codes to Breast Cancer Dx
Question: If a patient has current breast cancer, instructions for the C50.- codes tell you [...]

Practice Management:
Take These 6 Tips to Ensure Workplace Safety
Let OSHA standards and recommendations be your guide. In 2020, more workers in healthcare and [...]

Pulmonology Coding:
Identify the Correct ICD-10-CM Codes for Cystic Fibrosis
Use 4th and 5th characters for CF with manifestations. According to the Cystic Fibrosis [...]

ICD-10-CM Coding:
Remember the 7th Character in Complication Coding
Question: I work at a behavioral health facility that offers transcranial magnetic stimulation (TMS) treatment. [...]

Medicare Regulations:
Fight Back Against Parenteral Nutrition Claim Denials
Don’t let parenteral nutrition claims tank your patient care, compliance, or revenue cycle. Parenteral nutrition [...]

Oncology/Hematology Coding:
Get the Answers to Your Frequently Asked Ovarian Cancer Coding Questions
Understand functional activity to paint the complete picture. Even the most experienced oncology coder can [...]

Pediatric Coding:
Don’t Sugarcoat This Gummy Encounter
Question: A 14-year-old existing patient was brought into our office after their parent found them [...]

Diagnostic Radiology Coding:
Code Head, Brain, and Neck CT Scans With This Detailed Guide – Part 1
Explore the many reasons why head, brain, and neck CT scans are performed. Computed tomography [...]

General Surgery Coding:
Assess These Ablation Differences
Question: The surgeon’s operative report mentions they used laser ablation to control the patient’s bleeding [...]

Neurology & Pain Management Coding:
Name Gait Abnormality, Nail Dx Coding
Question: If a patient has a diagnosis of abnormal gait, am I able to assign [...]

Anesthesia Coding:
How to Code Services Involving Triple Lumen Catheters
Know which CPT® codes to look to for insertion, repair, replacement, and removal. A triple [...]

Ob-Gyn Coding:
Use This Practical Guide to Confidently Code Obstetric Ultrasounds
Learn the difference between a standard complete exam and a detailed fetal anatomic exam. Obstetric [...]

Otolaryngology Coding:
Pick These Codes Only for Post-Surgical Tonsillectomy Care
Question: I have a question about the tonsillectomy/adenoidectomy hemostasis codes (42960-42972). Are they for use [...]

Anesthesia Coding:
Rely on Areola Tissue Definition for Correct Procedure Code
Question: How is an injection to the areola coded? My provider wants me to use [...]

Cardiology Coding:
Atrial Fibrillation Ablations: A Practical Guide to Submitting Medical Claims, Part 2
Don’t forget to distinguish between the primary procedure code and add-on codes. Knowing how to [...]

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