How does documentation specificity affect diabetes code assignment?

The details included in a medical record can significantly affect ICD-10-CM code assignments. Terry discusses several examples to show how documentation specificity, provider links between conditions, and medication use can influence diabetes coding.

There are certain conditions for which a cause-and-effect relationship with diabetes can be assumed under coding guidelines; however, not every condition can automatically be considered related to diabetes. When a provider specifically links a condition to diabetes, that documentation can provide crucial support for accurate code assignment.

Tune in today for some insights into the frequent, although challenging condition to code.

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Terry gives us scenarios that are examples of work that doesn’t amount to an E/M service or can’t be counted toward an E/M service, followed by discussion of the reason why along with similar situations where it might be appropriate to report a stand-alone E/M service or count it toward an E/M service. We have to make sure we are not caught in the FWA that is happening all over the country. Listen in this week to protect your practice.

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The AMA specifically states that the risk element concerns patient-management decisions made by the physician/QHP reporting the E/M service. It also emphasizes that surgical risk depends on the particular patient’s circumstances and risk factors as assessed by that physician. Terry discusses “pre-op clearance” visits today and their level of risk, along with the billing of 76937 controversy.

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Terry discusses the 1op 10 Coding Corner Membership questions of the quarter, including Telehealth, the reality of voice recognition transcription disclaimers and some of the new proposals from CMS slated for 2027. Tune in to get the rundown.

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Today on the CodeCast Podcast, Terry discusses a topic that comes up in auditing conversations frequently: “that an auditor needs to specialize in a certain specialty before they can audit E/M services for that specialty.” That is not necessarily true.

I understand where that thought comes from.

It can absolutely help for an auditor to be familiar with the anatomy, medications, terminology, and common treatment plans within a specific specialty. That knowledge can make the note easier to follow. It may also help the auditor know when they need to ask a question or do additional research. But does it also create a bias?

Let’s chat about this today on the CodeCast.

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What are we anticipating for 2027 in the MPFS? This week Terry gives us a rundown on what to expect, how to respond before the comment period ends, and what needs to happen to strengthen our private practice providers. Listen in…

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Incident-to Billing Update: More Blue Cross Blue Shield plans, along with the three largest commercial insurance carriers, are tightening their policies on the reporting and reimbursement of services billed under Medicare’s “incident-to” guidelines.

In today’s episode of the CodeCast Podcast, Terry reviews these recent policy changes, highlights key effective dates, and explains what physicians, coders, billers, and practice managers need to know before submitting claims. Tune in to learn how these evolving payer requirements could impact your reimbursement and the compliance steps you should be taking now.

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With more patients turning to large-language models such as ChatGPT, Gemini, Claude and others to answer their questions about symptoms, medical conditions and more, the American Medical Association (AMA) is offering some go-to advice that will help patients get more out of their experience with AI chatbots while staying safe.

The key to effectively using AI chatbots, is to understand they are not a replacement for a physician. Terry discusses the AMA 5 steps to AI ChatBot safety and what physician practices need to do to protect patients in this uncertain and sometimes, unchecked reality. AI chatbots are not as a substitute for the evidence-based, personalized guidance of an actual doctor.

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In today’s episode of the CodeCast podcast, we’re breaking down why E/M time belongs to the physician or qualified healthcare professional performing the service, why time from other team members cannot be combined to support the E/M level (in the office setting), and an important Medicare reminder: shared visits do not apply in the office or other outpatient setting.

Let’s dive into the rules so you can code with confidence and avoid a common compliance pitfall.

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Terry tackles a growing compliance issue in telehealth: where the patient is located at the time of the visit. While physicians generally must be licensed or otherwise authorized to practice in the state where the patient is physically located, evolving payer policies and Medicare rules have added new layers of complexity.

From commercial insurance requirements to CMS guidance on services provided outside the United States, Terry explains what providers need to know to remain compliant and avoid costly reimbursement pitfalls.

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