Emergency Department (ED) - Medical Coding Guide

Coding guide for Hydration CPT codes 96360 and 96361

April 11, 2023April 11, 2023 Jitendra M.Sc CPC

Coding guide for Hydration CPT codes 93960 and 93961

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 minutes or less is not reported using infusion codes. Some chemotherapeutic agents and other therapeutic agents require pre- and/or post-hydration to be given in order to avoid specific toxicities. A minimum time duration of 31…

Emergency Department Coding Rules (CPT 99281-99285)

April 10, 2023April 10, 2023 Jitendra M.Sc CPC

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 medical attention. Since the codes now based only on level of medical decision-making. Their are elements that will help determine the correct MDM level for ED services. Below are few of them Possible number of…

Sample Coded Report for CPT code 99282

April 9, 2023November 8, 2023 Jitendra M.Sc CPC

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 change in her baseline vision. She denies ha but had 15 seconds of pain lateral to her eye last night. She has a history of 3 eye surgeries. One was a cataract surgery. Medical Decision…

Emergency Department (ED) Sample Medical Coding Chart Part 1

March 31, 2023November 12, 2023 Jitendra M.Sc CPC

Emergency Department (ED) sample medical coding chart 1 Chief Complaint & History of Present Illness : 19 year old male presents for headache.Patient states his symptoms started approximately six days ago with a left sided headache.He describes his pain as a throbbing sensation on the left side of his head and rates the pain as a 4/10.His symptoms got progressively worse and he developed visual disturbances.He had one episode of emesis today.Patient denies fever and ear pain.He notes that he was taking Aspirin and Advil for his symptoms.Patient denies…

Coding guide for Emergency Department (CPT code 99281-99285)

March 16, 2023May 21, 2023 Jitendra M.Sc CPC

Basics of ED CPT code 99281, 99282, 99283, 99284 and 99285 The emergency department is defined as an organized, hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. It must be available 24 hours per day. Any physician seeing a patient registered in the emergency department may use emergency department visit codes. It is not required that the physician be assigned to the emergency department. No distinction is made between new and established patients in the emergency department. E/M services in…

Awesome tips for Coding an ED report

March 5, 2022March 21, 2022 Jitendra M.Sc CPC

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 about ICD and CPT coding guidelines, they become expert in coding. I always say that having CPC certification from AAPC and having experience in multiple speciality coding, will always boost your career growth. I see…

How to correctly report the E/M add-on G codes

June 14, 2021April 10, 2023 Jitendra M.Sc CPC

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 practitioner may report prolonged office/outpatient E/M visit time using HCPCS add-on code G2212 (Prolonged office/outpatient E/M services). Practitioners should not report prolonged office/outpatient E/M visit time using CPT codes 99354 and 99355 (Prolonged service with direct patient…

E/M Coding Guidelines based on TIME

January 15, 2021October 4, 2021 Jitendra M.Sc CPC

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 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use time…

Guidelines for Office or Other Outpatient E/M Services

January 15, 2021October 4, 2021 Jitendra M.Sc CPC

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 supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of…

2021 E/M coding changes for Medical coders

November 26, 2020 Jitendra M.Sc CPC

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 to document every diagnosis a patient has received—just those being addressed during that visit. The amount or complexity of data to be reviewed and analyzed. This reduces cut-and-paste note bloat by not requiring physicians to…