With all of the AI implementation into EHR and EMR systems, there is concern about how providers rely on these AI shortcuts more than ever. Without proper safeguards, accountability, and compliance perimeters, relying on AI could be problematic.

Terry discusses the red flags to look for and how to proceed with caution in this new world of technology.

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The post Did you know AI is integrated into EMRs? appeared first on Terry Fletcher Consulting, Inc..

The 2023 CPT® Errata and Technical Corrections added a one-liner on Independent Interpretations that responds to the question, “Can a practitioner get credit for both ordering and interpretation of a test, if documented?”

In this episode of the CodeCast podcast, Terry answers this question referencing the March 2023 CPT® Errata and Technical Corrections. She also covers the reality of this change and what an independent interpretation means, so that you are not upcoding based on assumptions.

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The post Can you get credit for ordering and interpretation of a test? appeared first on Terry Fletcher Consulting, Inc..

The 2021/2023 E/M guideline revisions read: “The evaluation and/or treatment should be consistent with the likely nature of the condition.” Before this, the CPT® guidelines did not discuss medical necessity. Guidance was left to the payers, particularly Medicare, via the Social Security Act.

CMS’s guidance doesn’t necessarily hold regulatory authority. However, it often reflects a new, shared understanding that medical services reported should meet documentation standards for level selection. Those standards should also appropriately indicate why the patient is visiting the provider, based on the presenting problems.

This episode of the CodeCast echoes Terry’s insights that auditors, coders, and medical professionals focus on medical necessity first, then look to coding.

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The post Medical Necessity Comes Before Coding appeared first on Terry Fletcher Consulting, Inc..

It’s time for another round of frequently asked questions as Terry’s expertise covers orthopedic surgery, imaging, data points for E/M, and administrative charges for practices.

She also answers questions relating to multiple E/Ms on the same date by the same and different physicians from the same group practice.

Tune in for a lot of good information covered on this week’s show.

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The post Top 10 Tuesday Q&A – Coding, Billing, and Compliance Questions appeared first on Terry Fletcher Consulting, Inc..

We all know the age-old question, “Where does it say that?” In this episode, Terry brings receipts, explaining it’s been this way since 2003:

“Reviewing results of laboratory tests, phoning results to patients, filing such results, etc., are Medicare-covered services. Payment is included in the physician fee schedule payment for the evaluation and management (E/M) services to the patient. The CPT lists different levels of E and M services for both new and established patients and describes services that are included as E/M services. Such activities include obtaining, reviewing, and analyzing appropriate diagnostic tests.”

Tune in to this episode for an in-depth discussion as Terry details trying to report a telehealth visit for giving test results may be considered double-dipping: and can get you into hot water!

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The post Giving Tests Results to Patients… Where’s the Payment? appeared first on Terry Fletcher Consulting, Inc..

An ADR (Additional Documentation Request) is a request from CMS or another insurance payer for additional documentation to review a claim. Most of these requests come from payer investigative units looking for medical necessity support.

Terry discusses how to handle these requests, as well as how to ensure they are addressed promptly to meet the deadlines typically associated with them.

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The post ADR Workflow Tips appeared first on Terry Fletcher Consulting, Inc..

If the provider discusses their preferred management options with the patient, do they receive the “risk” credit even if the patient declines it? If yes, how long do they get to capture it?

Terry breaks down, citing references, how to handle this MR element and ensure the providers are receiving the correct “risk” value for their encounter. Listen to this episode for all of the details.

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The post Who Gets the Credit for MDM Risk Element? appeared first on Terry Fletcher Consulting, Inc..

In this episode of the CodeCast podcast, Terry discusses the differences between APCM and CCM services and what is needed to report either.

Compliance issues are seen with many care management service records. Terry covers how to follow best practices to ensure you follow the published guidance.

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The post APCM Focus appeared first on Terry Fletcher Consulting, Inc..

Medical Coding provides standardized language that ensures all healthcare providers involved in a patient’s care are on the same page.

The coder’s role is to be accurate, communicative, insightful and focused on a positive patient outcome. A patient’s financial health can impact their clinical health, and medical coders need to be recognized for their role in this process.

Terry shares her thoughts on what makes a coder valuable, even if they are less visible than the providers.

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The post The Crucial Role of the Coder in Quality Patient Care appeared first on Terry Fletcher Consulting, Inc..

This week’s CodeCast summarizes the recent ICD-10-CM documentation guidelines instructions on sepsis, obesity, and COVID-19 reporting.

Terry also provides more guidance on E/M risk in prescription drug management and caution with PSAs in patient documentation.

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The post ICD-10-CM April 1st Updates appeared first on Terry Fletcher Consulting, Inc..