The most impactful overhaul to the E/M coding and documentation guidelines in 25 years went live January 1. The updated guidelines eliminate medical history and physical examination as required elements for reporting E/M codes 99202-99215. E/M coding for outpatient visits is now based on documentation of medical decision-making (MDM) or time spent on the encounter.
Regular monitoring and internal auditing are critical to ensure compliance throughout the revenue cycle and protect revenue integrity. Consider the different strategies that can be applied to documentation and chart audits, coding audits, and more.
Coding for traumatic fractures is based on details about the broken bone and the event that caused the injury. Review ICD-10-CM codes and guidelines for reporting different types of traumatic fractures.
Medical decision-making is one of the key components of E/M code selection. Review the guidelines to ensure correct coding and to improve internal audits.
Q: A patient was admitted to our facility with COVID-19-like symptoms, tested negative for COVID-19. Several days later, however, the patient was retested and found to be positive for COVID-19. Should we query the physician or assign a present on admission (POA) indicator of "no" or "unknown"?
Identifying and appropriately coding present on admission (POA) indicators in COVID-19 patients continues to challenge coders. Use these scenarios to check your knowledge and learn how to improve.
