EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Dec. 3 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. A Medscape survey popped up in my email a few weeks ago. The title was, “Is Technology Replacing Patient History?” (https://www.medscape.com/viewarticle/921235) and it linked…

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…

HCCs thrive on specificity and ICD-11 will provide a higher level of specificity than in ICD-10. For those of you who are coding for hierarchical condition category (HCC) purposes, you know that HCCs are categories of related ICD-10 codes. Only selected significant conditions to drive a payment HCC. That means…

Providers should review their protocols to prepare for the changes. The 2020 updates to ICD-10-CM contain some significant changes to Chapter 12, Diseases of the Skin and Subcutaneous Tissue. These changes include the addition of new codes for the reporting of pressure-induced deep-tissue damage, also known as deep-tissue pressure injury…

Late physician signatures pose serious issues. In the last few months, I have had questions about late signatures on documentation come in from several clients. I've been hearing about providers signing their notes a very long time after the encounter – sometimes weeks later, sometimes months,  and sometimes even turning…

More than half of physicians have experienced burnout, according to WHO. The World Health Organization (WHO) has classified physician burnout as an occupational phenomenon.     The WHO is clear that this is not a medical diagnosis. There are some estimates that more than half of physicians have experienced burnout. This…

Providers should have the choice of bringing into the record what they deem to be relevant and important. I am currently doing a project assessing emergency physicians’ documentation from disparate sites, and I am finding that they each have a different electronic health record (EHR) and/or template. Some are pleasing,…

Contest indicates coding accuracy is below expectations. Central Learning is a web-based coding assessment and education application. Since 2016, the company has conducted an annual national coding contest to measure ICD-10 coding accuracy and production. The initial premise was to evaluate how coding accuracy and production work, compared to ICD-9.…

Documenting challenges with EHR usage. Last week, I started telling you about a Law-Medicine combined conference I attended through Case Western Reserve University School of Medicine about EHRs and Safety concerns. I am going to continue with the speakers and review the assigned readings. The speakers referred to, and the…

“Virtual" peer reviews are a covered benefit for most payers. In keeping with our theme of “communication-based services,” let’s take a closer look at the inter-professional consults and referrals that do not include a face-to-face encounter with a patient. Some are existing CPT® codes, and two new codes, in this…