E/M Coding: What Not To Do

Terry gives her insights into Pain Management compliance when it comes to opioid rechecks. Automatically considering every routine three-month opioid management visit a moderate-complexity E/M service (99214), can be an audit mistake. However, under the AMA CPT E/M guidelines, a stable chronic pain patient receiving continued prescription opioid therapy can qualify for 99214, even when no medication changes are made. The distinction is whether the documentation supports moderate medical decision-making (MDM) rather than simply documenting that the patient takes opioids and receives another prescription. This is an important compliance issue for pain management practices because routinely assigning 99214 to every opioid refill appointment without evaluating the MDM of each encounter creates potential audit exposure. Further, opioid dependence should not be coded (ICD-10-CM) unless the provider’s documentation supports that diagnosis. However, I would caution against automatically substituting F11.90 (Opioid use, unspecified, uncomplicated). There is an important distinction between a patient who is prescribed opioids for chronic pain management, a patient who has developed physiological dependence, and a patient who has an opioid use disorder. Listen in today to get this right! Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Pain Management E/M: the Myth of level 4 appeared first on Terry Fletcher Consulting, Inc..

As flu season approaches, physician practices may find themselves navigating planned leaves of absence, unexpected illnesses, or other staffing interruptions. But when a physician or physical therapist needs to be away, does your practice understand Medicare’s rules for bringing in a substitute provider? Formerly referred to as locum tenens, Medicare’s substitute physician and physical therapist billing arrangements can help practices maintain continuity of patient care while protecting revenue during a provider’s absence. However, the 60-day limitation is one of the most misunderstood aspects of these arrangements, and getting it wrong can expose practices to claim denials, overpayments, and costly recoupments. In this episode of CodeCast, Terry breaks down Medicare’s substitute provider billing rules. Don’t let a temporary staffing solution turn into a permanent compliance headache. Tune in to this episode of CodeCast! Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Substitute Physicians – formerly Locums Tenens and the CMS 60-day rule appeared first on Terry Fletcher Consulting, Inc..

The FY 2027 update takes effect October 1, 2026, for outpatient encounters and inpatient discharges beginning on that date. Both the diagnosis code changes and the updated Official Guidelines for Coding and Reporting deserve attention. When Terry reviews an annual update, she thinks about the entire process. The provider documents the condition, the physician or coder selects the diagnosis, and that selection makes it onto the claim. In today’s CodeCast Podcast, Terry gives a specialized overview of the new ICD-10-CM codes for the 2027 FY effective date October 1st, along with some educational tips for providers and coders. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post ICD-10-CM 2027 Update appeared first on Terry Fletcher Consulting, Inc..

Few questions get a stronger reaction from Terry than, “How can I get around that rule?” When providers, coders, or other healthcare professionals ask how to work around a coding, billing, or regulatory requirement, Terry’s response is clear: compliance isn’t about finding a loophole—it’s about understanding the rules and applying them correctly. In this episode, Terry breaks down her position using regulatory guidance, coding and billing requirements, and established compliance principles. The goal isn’t simply to get a claim paid; it’s to support accurate reporting, defensible documentation, ethical billing practices, and the highest standards of professional integrity. Listen in for the latest discussion in our ongoing pursuit of the truth—where facts, guidance, and compliance come before shortcuts. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Please don’t try to get around the Healthcare System appeared first on Terry Fletcher Consulting, Inc..

Terry discusses the specialty of Podiatry procedural coding, to include some ankle surgeries, and other complex foot surgeries. She also strongly advises not to add CPT or ICD-10-CM codes to operative reports as this now handcuffing the provider to those codes whether they are over or under coded or incorrect as this report would suggest. Listen in to get the details. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Podiatry Procedural Coding appeared first on Terry Fletcher Consulting, Inc..

Obstetric coders have likely started to report E/M visits for newly pregnant patients, but they still have a few months before they need to use the full set of new and revised codes and guidelines for maternity care services as we head into 2027. Terry brings in some recent questions and answers to to help train your team and determine where more research or training is necessary before the full code system goes into effect Jan. 1, 2027. A contributing article in Part B news from 9/28 also was used for this episode. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Obstetrics Coding for 2027 appeared first on Terry Fletcher Consulting, Inc..

Emergency Department and Critical Care Services are often incorrectly coded because the documentation lacks clarity. Terry discusses the elements necessary to have compliant ER documentation and also what CC services need to make sure they are supported for billing. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post ER and Critical Care Services Coding appeared first on Terry Fletcher Consulting, Inc..

CMS has made permanent the policy that allows a practitioner who furnishes Medicare telehealth services from home, even what the height of COVID is over 3 years in the past. There is also confusion is what is listed as the physician’s practice location? Terry discusses the answer to this question, as the CCHPCA has now a specific position, and also talks about the difference between Medicare enrollment vs. POS where services are performed. Different rules apply when the practitioner or group operates virtually and has no other physical practice location, and teleradiology is subject to separate enrollment rules. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Telehealth when the physician is at home appeared first on Terry Fletcher Consulting, Inc..

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. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post ICD-10-CM Coding for Diabetes appeared first on Terry Fletcher Consulting, Inc..

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. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post E/M Coding: What Not To Do appeared first on Terry Fletcher Consulting, Inc..