Tips & Expertise: 2021 E/M Changes

Q: Can we count resident’s time?A: No. Teaching physician rules haven’t changed. Resident time is not billable. Q: Do you need to document exactly how you spent your time with the patient, or just the total minutes?A: It is recommended to document total minutes plus...

Tips & Expertise: Coding Diabetes

Q: When is code I12.9 used?  I thought that was for hypertension with CKD without CHF? A: Code I12.9 is for hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease.  This code is used when the...

Tips & Expertise: Liver Disease & Treatment

Q:  Question about fatty liver disease.  It’s my understanding that fatty liver disease is often the first stage in liver disease and can progress to cirrhosis.  If the provider documents fatty liver disease as well as cirrhosis, should you code both or is the...