Proper Use of Surgical Modifiers: Co-Surgeon, Assistant-at-Surgery, and Team Surgery

Understanding the appropriate use of surgical modifiers is essential for accurate coding and compliance. Recent audits by the Office of Inspector General (OIG) have revealed significant billing inaccuracies related to co-surgeon and assistant-at-surgery procedures, underscoring the need for careful review and application of relevant guidelines. OIG Findings on Modifier Usage In a November 2022 report, … Read more

Understanding CPT Code 99024: Compliance and Reporting for Post-Operative Services

Medical coders play a vital role in ensuring accurate and compliant documentation of services rendered by healthcare providers. One such code, CPT 99024, is integral in reporting post-operative evaluation and management (E/M) services included in the global surgical package, especially for providers reimbursed through Medicare or Medicaid. Background and Importance In a 2012 report, the … Read more

Expert guide on Assigning Diagnosis Codes for Diagnostic Radiology Services

Assigning accurate and complete diagnosis codes for diagnostic radiology studies—such as X-rays, CT scans, MRIs, ultrasounds, and mammograms—can present a unique challenge, even for experienced medical coders. Unlike other clinical services, diagnostic radiology reports are based on interpretations by radiologists who typically do not have direct patient interaction. Instead, they rely on information provided by … Read more

Optimizing Debridement Documentation for Accurate Medical Coding

Accurate debridement documentation is crucial for proper medical coding and reimbursement, yet it is often challenging. The documentation must be sufficiently detailed to paint a clear picture of the procedure performed. However, the procedure title and description in the operative note often do not align, making it difficult to capture the appropriate coding information. Key … Read more

Mastering Medical Decision-Making (MDM): A Simplified Guide for Coders

Medical Decision-Making (MDM) can be a complex and confusing process for medical coders. However, by understanding key concepts and following a simplified system, coders can accurately determine the appropriate MDM level for a given case. This article breaks down MDM and its components, providing a clear guide to help coders make more informed decisions. What … Read more

Mastering Medical Coding Modifiers: Unlocking Full Reimbursement Potential

As a medical coder, knowing when and how to use modifiers is crucial to ensuring you’re getting paid properly for services provided. One of the most powerful tools at your disposal, modifiers help you communicate that certain procedures, even within a global surgery period, are distinct and deserve separate payment. This is your secret weapon … Read more

Mastering Hip Replacement Coding: A Guide for Medical Coders

As a medical coder, mastering the language of orthopedics is essential for ensuring your coding is on point—especially when it comes to procedures like arthroplasty and joint replacement. While these terms are often used interchangeably, understanding their subtleties can make a huge difference in accurately translating clinical language into the precise codes used in medical … Read more

Update for Medical Coders: ICD-10-CM Code Changes Coming April 1, 2025

Get ready for some important ICD-10-CM updates that are sure to keep you on your toes! While CMS has announced there will be no brand-new ICD-10-CM codes introduced on April 1, 2025, don’t tune out just yet – they’ve released key diagnosis code update files for discharges and patient encounters from April 1 through September … Read more

Essential Updates to Vaccine Codes for 2025: What Medical Coders Need to Know

Vaccine codes, including those for immunizations and related procedures, are frequently updated, especially when new vaccines are introduced or billing requirements change. The American Medical Association (AMA) has updated the CPT code set to reflect these changes for the 2024-2025 period. In addition to updates for the influenza season, two new vaccine codes have been … Read more

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