Blog & Publications

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CPT Coding for Foot Procedures

Anyone who has coded or attempted to code for procedures on the foot and toes has no doubt discovered the complexities of the CPT codes. It’s impossible to code for them without a thorough understanding of foot and toe anatomy. Additionally, many providers refer to these procedures by eponyms which can confuse when it comes to code selection. Continue reading to learn more about these complex cases. | Read More.

Feeling Detached from Foot Amputation ICD-10-PCS Coding?

Blog Post: Digging into HIM & Coding

When was the last time you really thought about the marvel that is your foot? The human foot is composed of 26 bones, 33 joints, and what seems like endless tendons and ligaments. The number of body parts alone make coding podiatric procedures complex. And much like Paul Simon’s claim that there are 50 ways to leave your lover, there seems to also be 50 ways to amputate a foot. | Read More.

Telehealth Billing During the COVID-19 National Emergency

Publication: MGMA

The Centers for Medicare & Medicaid Services (CMS) recently released numerous waivers along with new rules for billing professional telehealth services during the public health emergency (PHE) of COVID-19. These changes, currently in place for the duration of the PHE, aim to ensure that patients have access to physicians and other qualified healthcare providers while remaining at home. Continue reading to learn about the types of services available to all Medicare beneficiaries, including telehealth, virtual check-ins and telephone visits, e-visits and remote patient monitoring. | Read More.

Hand Surgery Coding in CPT

Blog Post: Digging into HIM & Coding

Our hands may the the body part we most take for granted relative to their importance to our existence and our day-to-day activities. They are amazingly intricate and comprised of many different body systems and incur injuries and conditions that often demand the expertise from a number of surgical specialties including Plastic surgery, Orthopedic surgery, Vascular Surgery, Rheumatology, and of course Hand surgery. This assures that hand surgery is a constant challenge for coders. | Read More.

Defining an Organization’s Legal Health Record

Blog Post: Digging into HIM & Coding

As a health information professional with years of experience, I’ve seen the definition of the Legal Health Record (LHR) change with the emergence of the electronic health record (EHR). As a custodian of medical records, a designated position at most hospitals, maintaining and producing a complete, standardized LHR upon request is an essential part of the job. Some specific items that should be considered for inclusion (or exclusion) when defining an organization’s evolving LHR for business and litigation purposes are outlined here. | Read More.

Three Lies I’ve Told About Facility Emergency Department E/M Coding

Blog Post: Digging into HIM & Coding

For many, the ins and outs of facility evaluation and management (E/M) coding for emergency department (ED) services are shrouded in mystery.  In an industry where everything seems to be regulated, there appears to be a lack of regulation in the world of facility ED E/M.  But is there really?  I’ve been known to fib a little about facility ED E/M coding but quickly backtrack to simply state, “It’s complicated.”  So without further ado, here are three little lies I’ve told about facility E/M coding and the real truths behind them. | Read More.

ICD-10 Remix: What the Heck is a DRG and Why Should I Care About Case Mix?

Blog Post: Digging into HIM & Coding

So you want to be a coder. And not just that, you want to be a hospital coder because, on average, they make more money than physician coders. And you don’t just want to be a hospital coder, you want to be an inpatient hospital coder because then you get to look at the whole chart and piece together the patient’s clinical picture. If this is your goal, then everything you need to know you will not learn in school. And that’s mainly because there is so much to learn and practical experience is key.

If you want to be an inpatient coder, you need to know diagnosis-related groups (DRGs) because in hospitals, it’s all about DRGs and case mix – and compliance. If you have no idea what I’m talking about, fear not – here’s a primer on DRGs! I wish I could say I cover it all here, but this is just a beginning! | Read More.

Top 10 Things to Know About 2021 E/M Changes

Blog Post: Digging into HIM & Coding

E/M changes are coming. Lucky for us, we have almost a whole year to figure them out! They are set to take effect on January 1, 2021. The American Medical Association (AMA) has published the changes, as well as numerous tools to assist us. Let’s take a closer look at our Top 10 List of Things you need to know about these new changes! | Read More.

Diagnostic Coronary Imaging vs. Guiding Shots

Blog Post: Digging into HIM & Coding

One of the most complex areas of coding for cardiac catheterization procedures is determining when to code a diagnostic heart angiogram (imaging) separate from a percutaneous coronary intervention (PCI). The guidelines for reporting separate diagnostic imaging are found under the heading Therapeutic Cardiovascular Services and Procedures on the Coronary Vessels (92920-92979) in the CPT book. The National Correct Coding Initiative (NCCI) manual gives guidance that has left many scratching their heads wondering what is medically necessary. Continue reading to learn what the NCCI has to say as well as a couple of hard and fast rules to guide you. | Read More.

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