With state-to-state PHE mandates expiring, extending, or not renewed, Terry takes a look at where half of the country, and the government, is on the PHE, as we look to Telehealth compliance and continuing to make sure we are following the rules of reporting.

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Terry’s passion shines in this episode, as she discusses government-ordered vaccine mandates.

Staff shortages in ASC’s are prompting them to suspend services. This begs the question: are these mandates helping or hurting our communities?

Giving employees a choice of getting a vaccine, versus weekly testing and PPE for safety, should be considered. Our patients need access to care. These mandates are not servicing that cause.

Also, discussed are hip pathological fractures and treatment. You won’t want to miss this episode!

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The fiscal year 2022 ICD-10-CM diagnosis code updates will become effective on October 1.

There are eight key things to know: and Terry is on top of it in this episode of the CodeCast Podcast.

Some of the new rules include coders and physicians on the same page, laterality capture by “other clinicians” and SDoH clarified some homelessness status’.

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Terry discusses best practices for coders when questioned and their ability to communicate logical answers to back up their assessments. Many coders may struggle with this newfound communication concerning the daily challenges of maintaining productivity.

Coders are relearning time management and organizational skills to better manage productivity, including email communication in their workday. Especially with increased email communication in other health information teams (CDI, QA, Case Management) related to clinical documentation and coding accuracy.

Listen to discover how to be a “team” player and a better communicator.

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Terry discusses, the importance of Coding With Authority and accuracy when coding and reporting services.

She emphasizes making sure you read your code descriptor and also try to not get your terms mixed up. (Such as supervision vs. scope of practice.)

Also discusses are the importance of authoritative references, and a bonus discussion on the 99358 prolonged service code (and when it is appropriate to use).

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This week on the CodeCast podcast Terry discusses a variety of healthcare industry headlines, including new ABN instructions, a delay in certain NSA regulations, and EM 2021 Coding questions (to clarify Data Point counts).

It’s a packed episode this week, you won’t want to miss it.

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Kicking off the CodeCast in September, Terry discusses auditing and the objectives of looking for documentation support of the E/M record.

Terry focuses on not losing sight of “medical necessity” within the record and making sure the physician (or provider) can justify not only the level of E/M service but also the ordering of tests on a specific DOS.

She also advises on how to respond to a physician when they believe that only the physician should make clinical judgments on the documented record, even in an audit.

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In this month’s Top Ten Tuesday CodeCast, Terry discusses what a chronic condition is versus a symptom, EEG coding, and shared visit compliance.

We have a mixed bag of coding and compliance questions that will shed some light on multiple specialty issues that are making headlines this month.

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Terry fractured her thumb this week… so in the spirit of personal knowledge, she discusses five frequently asked questions on pathological fracture coding for ICD-10-CM!

Also, Terry revisits improving medical practice receivables and collection practices: while providers are on vacation and we are focused on working our A/R’s.

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This episode of the CodeCast Podcast focuses on physician documentation as it relates to coding. There is a saying, “There is no coding without documentation, doctors are required to use words.” AHIMA and AHA stand behind this statement.

More and more I am seeing coders making leaps to moderate and even high risk for patient encounters, when there is no link, narratively, in the record made by the physician.

I want to talk about this as a compliance, and coding issue.

The Coding Clinic says yes, doctors are required to write words, and they go on to remind coders that ICD-10-CM is a statistical classification. The role of physician documentation is inherent in the use of the code set – because the process of coding is the translation of physician documentation into codes.

Check out this week’s program to understand how to make this process more compliant in your work-flow.

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