Q: If an individual requests an electronic copy of protected health information (PHI) and the covered entity (CE) maintains that particular record only on paper, what is the standard procedure? Can a paper copy suffice? Does the covered entity need to find a way to deliver the record electronically?
Q: It seems that telemedicine is here to stay, but perhaps not every patient is ready to use telemedicine. What are your best strategies for assessing a person's abilities with technology?
Q: During an outpatient visit, a nurse reviews the patient’s medical history and a physician performs an examination in the presence of the nurse. If you adhere to the 2021 E/M guidelines and use time as the controlling factor for code selection, can you report one E/M code for these shared services?
Q: Under what circumstances can a CE disclose PHI to family and friends of the patient? Does the patient always need to verbally consent to the disclosure? For example, if a patient brings a friend or family member with him or her into the emergency room, should the doctor assume that the patient is OK with the friend or family member being privy to PHI?
Our coding experts answer questions about reporting modifier -58 for physicians and facilities, developing a charge capture audit process, and interpreting the 2021 E/M guidelines.
