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...

Spinal Anatomy Coding

In a discussion about spinal anatomy, one of my coworkers once said, “It’s not so much that the spinal column is three-dimensional, it’s more five-dimensional.” I think that is an apt description of the vertebral segments that stack one on top of the other to compose...

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...