by Emily Lomaquahu | Apr 22, 2026 | Auditor Insights, Profee Coding, Webinar Q&As
Using scribes can help reduce documentation burden, but when that scribe is a physician assistant (PA) or nurse practitioner (NP), things can get complicated quickly. What Defines a Scribe? A scribe’s role is strictly to document the physician’s or NPP’s work during...
by Susan Bonham | Mar 31, 2026 | All Posts, Auditor Insights
Time-based E/M coding can be tricky, and audits often reveal a common mistake: including separately reported services in the total time. CPT® guidelines are clear—time spent on other billable services, travel, or general teaching unrelated to the patient’s management...
by Mary Bort | Mar 1, 2026 | Auditor Insights
Medicare has permanently expanded the definition of direct supervision for incident-to services, allowing supervising physicians to be virtually present rather than physically in the office suite. This major shift updates rules that had been in place for decades and...
by Deanna Upston | Feb 27, 2026 | All Posts, Auditor Insights
Accurate coding for adjacent tissue transfer procedures (CPT® 14000–14032) is essential—but are your operative reports giving payors what they need? Recent client questions and claim denials highlight a common documentation gap that coders should address. ...
by Emily Lomaquahu | Dec 23, 2025 | Auditor Insights, Inpatient Coding, Outpatient Coding, Profee Coding
Have you ever seen an encounter note in which your provider spends time talking through vaccines with a patient—answering questions, addressing hesitations, and explaining risks and benefits—only to have the patient say, “I’ll think about it?” CPT is attempting to...
by Shea Lunt | Dec 9, 2025 | All Posts, Auditor Insights
A recent OIG audit found that a Medicare Administrative Contractor (MAC) paid physicians for anesthesia services administered during facet joint injection sessions—even when documentation did not support medical necessity. The report estimates Medicare could have...
