E&M codes are the most frequently used codes in any physician practice. Change is coming to the world of evaluation and management (E&M) services. With the Physician Fee Schedule Final Rule for 2020 now published, we know there are big changes to be expected in 2021. The good news is…

Do your physicians and ancillary staff know the ICD-10-CM coding rules? Based on many years of personal experience, most physicians and ancillary staff who do not code really don’t know or understand the coding rules.  This is not particularly surprising, because even the best coders are sometimes confused by the…

Over the many weeks since the release of the updates to the ICD-10-CM Official Coding Guidelines for the 2017 fiscal year, I have had the opportunity to engage in multiple conversations about the most controversial guideline, which addresses the use of clinical indicators for code assignment.   Some of those conversations…

Physicians can benefit from the talents of their medical assistants, and possibly in areas other than ICD-10.Medical assistants (MAs) are typically members of physician office teams. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. They are among the…

One of the biggest lingering questions facing the healthcare industry today is this: how do we keep physicians from becoming administrators rather than clinicians?Having a quality clinical documentation improvement (CDI) program in place can grant physicians the necessary flexibility and time to dedicate to their patients while still providing an…

As I was listening to a recent broadcast of Monitor Mondays, I was a bit taken aback when I thought I heard the phrase “the physician writes down the diagnosis, and it should be accepted as the diagnosis.”

Functional quadriplegia (R53.2) is defined as “the inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the brain or spinal cord,” describes Richard Pinson, MD. This oft-overlooked secondary diagnosis may have significant impact on the final MS-DRG, relative weight, length…

The statistics are striking: Between 2002 and 2013, heroin overdoses in the United States increased by 286 percent, according to a Centers for Disease Control and Prevention (CDC) report. In 2013 alone, more than 8,200 Americans died due to a heroin-related overdose.  

The federal mandate for conversion of medical record-keeping to a purely electronic format for the purposes of developing statistics and its associated tracking of quality of healthcare delivery and billing for services (known as value-based purchasing) is virtually complete in the United States. 

So, how are we physicians coping with denials?  Despite the many apocalyptic predictions regarding the ICD-10 transition, for healthcare organizations and the nation, ICD-10 has moved along rather swiftly to date. By now, most of us have seen the Centers for Medicare & Medicaid Services (CMS) October statement, which noted…