Episode Summary: Our previous episode dealt with EMR issues relating to documentation quality and ease of use. In this follow-up episode, hosts Neal Sheth and Dr. Piyush Sheth explore concepts on creating a better user environment in EMRs and on a more global level, improving EMR infrastructure.

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Topics discussed in this episode: EMR, EHR, EPIC, Infrastructure

Full Transcript available at: unravelingmedicalcoding.com

Episode Summary: Electronic Medical Record software has  the potential to facilitate documentation and minimize errors. EPIC is the most widely used EMR in the United States. There are other EMR vendors. Despite their pervasiveness in healthcare, documentation quality in EMRs is often poor and prone to error propagation. A clear understanding of proper documentation is necessary for proper medical coding. Hosts Neal Sheth and Dr. Piyush Sheth explore EMR best practices as they relate to patient care and medical documentation.

Show links:

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Full transcript available at www.unravelingmedicalcoding.com

Episode Summary: Critical Care coding is complicated. There are clearly defined requirements that must be adhered to in order to bill this time-based service. Hosts Neal Sheth and Dr. Piyush Sheth explore the intricacies involved with Critical Care coding.

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Full transcript available at www.unravelingmedicalcoding.com.

Episode Summary: Physician extenders (physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives) can ease the burden of the physician shortage. Coding and billing for utilizing physician extenders in a medical practice can increase reimbursement, but only in certain situations. Hosts Neal Sheth and Dr. Piyush Sheth explore the nuances of using physician extenders.

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Full transcript available at www.unravelingmedicalcoding.com

Episode Summary: Physician extenders (physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives) can ease the burden of the physician shortage. Coding and billing for utilizing physician extenders in a medical practice can increase reimbursement, but only in certain situations. Hosts Neal Sheth and Dr. Piyush Sheth explore the nuances of using physician extenders.

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Full Transcript Available at www.unravelingmedicalcoding.com

Episode Summary: Office consultation coding requires three documentation items in addition to fulfilling the standard evaluation and management services documentation of history and physical exam.  These three items are:  Request, Reason, and Report.  The requesting physician must document a request to the consulting physician.  There must be a reason for the consultation.  And, the consultant must send a report of the consultation back to the requesting physician.  If these three criteria are not satisfied or there is a transfer of care, a consultation billing code cannot be billed.  Hosts Neal Sheth and Dr. Piyush Sheth explore these requirements in detail and resolve scenarios that highlight grey areas. Of special note is that Medicare no longer recognizes consultation codes.

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Full Transcript Available at www.unravelingmedicalcoding.com

Episode Summary: New medical documentation guidelines for Outpatient Office visits were implemented on January 1, 2021 as part of the “Patient’s over Paperwork” initiative by Medicare with input from the American Medical Association. These new documentation guidelines require a “medically appropriate” history and physical exam and are billed by either Total Time or Medical Decision Making.  Host Neal Sheth interviews Dr. Piyush Sheth regarding these guidelines including benefits and pitfalls and their impact on healthcare economics.

Resources:

AMA 2021 E/M Office visit changes:

E/M office visit changes (ama-assn.org)

AMA updated document regarding Outpatient Office visits:

Code and Guideline Changes | AMA (ama-assn.org)

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Full Transcript Available at www.unravelingmedicalcoding.com

Episode Summary: Medical coding and billing is complex. The International Classifications of Diseases version 10 (ICD-10) and the Current Procedural Terminology (CPT®) code sets are expansive. Furthermore, proper medical documentation using the Medicare Evaluation and Management Documentation guidelines from 1995 and 1997 make efficiency challenging. Host Neal Sheth interviews Dr. Piyush Sheth, author of Coding Solutions – General Surgery and Starting Medical Practice, to provide a brief overview of this complexity and his drive towards efficiency.

Resources:

Gallbladder chapter from Coding Solutions – General Surgery

https://drive.google.com/file/d/1KGFBdefXmed8GRB1zTA8MDNGaWPSumwD/view?usp=sharing

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Full Transcript Available at www.unravelingmedicalcoding.com