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.
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?
Q: A recent study by the California Lab Policy reported 50% of unsheltered individuals experience "tri-morbidity" (co-occurring physical health, mental health, and substance abuse challenges), compared to just 2% of sheltered individuals. What can case managers do to assist these patients?
