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Basics of Hydration CPT code 96360 & 96361 Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluids and electrolytes. Hydration services are reported by using CPT codes 96360 (initial 31 minutes to 1 hour) and 96361 (each additional hour). IV fluids reported for hydration lasting 30 … Read more
Emergency Department (ED) Coding basic information Their has been lot of updates in Emergency department coding this year and it has really made easy to choose levels in ED coding. Now, Medical Decision Making is the main factor to choose the level of ED CPT codes 99281-99285. Emergency department is basically for patients requiring immediate … Read more
Chief Complaint & History of Present Illness : cc: I have something in my eye HPI: this is a 67 yo female who has the sensation that something is in her eye. It began gradually last night. It is more irritated if she opens her eye but light does not bother it. SHe denies any … Read more
As a medical coder, I always wanted to learn all the coding facilities. The best thing I like about medical coding is that, you can learn everything here. The amount of knowledge you gain while coding a medical report is unbelievable. Initially people have difficulty in coding a medical report, but when they know everything … Read more
Hopefully, everyone is using the new E/M codes without issue. CMS added two HCPCS codes to represent “additional” time for E/M services. These are important qualifiers, as medical necessity audits are likely to follow. The latest instructions from CMS on proper use of the G codes: “When the practitioner selects a visit level using time, the … Read more
Time The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 is done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021 and except for … Read more
History and/or Examination Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may … Read more
Reducing variation in MDM coding Components for code selection were narrowed down to two: medical decision-making (MDM) and total time on the day of the encounter. Elements of MDM affecting coding for an outpatient or office visit include: The number and complexity of problems addressed in the encounter, meaning it will no longer be necessary … Read more