Category: Documentation

Analysis: AMA Responds to E/M Proposal

The AMA sent a letter to the Administrator of CMS on August 27, 2018 with signatures from most of the medical societies and state medical societies with comments on the CMS proposal for the “Patients Over Paperwork” initiative. AMA Loves Paperwork Red… For more, read here: AAPC Blog

How to Document E/M with Counseling and Coordinating Care

The only case when time may be used as the overriding factor in determining an evaluation and management (E/M) level is when counseling and/or coordinating care dominates the encounter, which means that the time expended on counseling and/or coordinat… For more, read here: AAPC Blog

E/M Documentation by Med Students Rules Clarified

The Centers for Medicare & Medicaid Services (CMS) issued a MLN Matters article ( MM10412 Revised) on May 31 with a retroactive effective date of January 1, 2018 clarifying documentation requirements when performed by Medical Students in a teac… For more, read here: AAPC Blog

OIG: Many Outpatient PT Claims Fail to Comply

The Office of Inspector General (OIG) did a study of physical therapy claims and documentation for Medicare patients and issued a report this month in March. Their findings are of great concern for the PT and rehabilitation specialty. The OIG reviewed… For more, read here: AAPC Blog

Case Studies: Modifier 59 and X[ESPU] Use

When I last wrote “Modifier 59 – To Use or Not to Use”, I promised to follow it up with some real-life examples of when we should be using the 59 or the new Medicare X[ESPU] modifiers. Let’s look at some clinical examples and first determine if the … For more, read here: AAPC Blog

Modifier 59 – To Use or Not to Use

I often call Modifier 59 the prednisone of modifiers. That is because it is very powerful and can do a lot for you, like prednisone is for the patient. But at the same time, it is a two-edged sword, the modifier 59 is exceptionally dangerous when used… For more, read here: AAPC Blog