More E/M Coding Questions (and Answers!)

April 29, 2024 This week, we pick up where we left off with the last issue of Coffee & Coding, when we addressed questions about how tests and lab work can count toward complexity of data in medical decision-making (MDM).1 The Role of Coders in Assessing Changes...

More Pro Tips & Tricks

April 15, 2024 Back by popular demand: We received such a positive response to our “tips and tricks” edition of Coffee & Coding that we’ve decided to make it a recurring feature each quarter. So, we invite you to grab a fresh cup of coffee and jump into a few...

The Problem with Independent Historians

April 8, 2024 In most cases, we know who independent historians are: mothers, fathers, guardians, grandparents, or adult children. But we still see many instances when the term is incorrectly applied in the documentation—mostly, it seems, because of misunderstandings...

Level 3 or Level 4: Getting It Right

March 18, 2024 Guidelines notwithstanding, deciding whether to apply Level 3 or Level 4 to a patient encounter isn’t always easy. In fact, we see a lot of inconsistency and confusion on this point. While many clinicians accurately code for the appropriate level of...

Ending Confusion Over Modifier 25

March 11, 2024 It’s a big week here in Boston (my hometown). Sunday, of course, is St. Patrick’s Day. Here in Boston, we also remember March 17 as Evacuation Day—marking the anniversary of the British army leaving the city in 1776. Either way, it’s a day to celebrate....