Medical coding has long been a crucial component of the healthcare industry, playing a vital role in accurately translating patient information into universally recognized codes. Considered the backbone of medical billing and healthcare documentation, medical coders bridge the gap between healthcare providers and insurance companies, ensuring proper reimbursement for services. However, with advancements in technology…
Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:For a physician to bill the initial observation care codes,…
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the…
When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the…
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: the ability of the…
Please submit the following code for the one-time Welcome to Medicare Visit:• G0402 Please submit one of the following codes for the Annual Wellness Visit:• G0438 (first visit)• G0439 (subsequent visit) In 2015, our plans also cover an Annual Routine Physical Examination by the member’s Primary Care Physician (PCP) and can be billed using the…
A: A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.• A substantive portion of an E/M…
“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting. Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the…
Palpation of scalp and inspection of hair of scalp, eyebrows, face,chest, pubic area (when indicated) and extremitiesInspection and/or palpation of skin and subcutaneous tissue (eg,rashes, lesions, ulcers, susceptibility to and presence of photodamage) in eight of the following ten areas:Head, including the face andNeckChest, including breasts and axillaeAbdomenGenitalia, groin, buttocksBackRight upper extremityLeft upper extremityRight lower…
Change Request (CR) 9434 announces that the Centers for Medicare & Medicaid Services (CMS) has determined that, effective for dates of service on or after July 9, 2015, evidence is sufficient to add Human Papillomavirus (HPV) testing under specified conditions. Make sure that your billing staffs are aware of this change. Medicare covers a screening…