Spinal Decompression

The report below describes a patient undergoing spinal surgery. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed. Do you have a complicated surgery case that needs help with coding? RT Welter…

Medical Necessity in E/M

As we move closer to 2021 and our new E/M guidelines, now is the perfect time to educate our clinicians on the importance of documenting their encounters to include medical necessity. In the January 2020 issue of CMS MLN on Evaluation & Management under the General Principles of E/M Documentation, we see this guidance; Clear…

Annual Preventive Visit w/ Illness Not Supported

Comprehensive, age-appropriate HPI & Exam support 99396 for preventive reevaluation & management of 1 established chronic problem. OMM of 1 body area is performed supporting code 98925. Questionable use of dx code Z12.4. Consider Z01.419 or Z00.00. Unsupported 99213, documentation does not support a separately identifiable E/M illness code. Possible use of code Q0091 for…

Stress Caused by Taking Time-Off

As many of us in the healthcare industry have stayed particularly busy throughout the past few months, it’s important to remember the need for time-off. Even though current situations have many of us canceling or changing vacation plans, one aspect of time-off is always the stress involved with being away. Read below for more on…