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Defeat the challenges that threaten your E/M claims and compliance success. Evaluation and management (E/M) services are the lifeblood of your revenue stream, and yet they’re the most problematic to report. Claim denials remain high. E/M coding errors, in fact, rose from 11.9% in 2018 to account for 12.8% of CMS’s overall 2019 improper payment rate. How much E/M revenue are you losing? Safeguard your organization from claim denials and audit scrutiny with the Evaluation & Management Coding Reference Guide. Our experts break down E/M coding rules and requirements into simple, manageable steps written in everyday language to boost your E/M reporting skills. Learn how to capture the key components of medical history, physical exam, and medical decision-making—and capitalize on real-world clinical scenarios to prevent over- or under-coding. The Evaluation & Management Coding Reference Guide will help you prep for 2021 E/M guideline changes overhauling new and established office and outpatient services, and walk you through online digital E/M services, remote physiologic monitoring, and more. Master the ins and outs of E/M coding—CPT® guidelines, level of service, modifiers, regulations, and documentation guidelines. Put an end to avoidable denials and optimize your E/M claims for full and prompt reimbursement. Benefit from expert tutorials covering the spectrum of E/M reporting concepts and challenges: Prep for 2021 guideline changes and their impact on your organization Master the ins and outs of E/M guidelines in CPT® Capture the seven components of E/M services Sort out medical decision-making coding Avoid the pitfalls of time-based coding Nail down specifics for critical care E/M services Clear up modifier confusion Understand NPPs rules for same-day E/M services Take the guesswork out of complexity determinations Get the details on coding surgery and E/M together Learn the principles of E/M documentation
"This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.
Master advanced coding skills! Buck's The Next Step: Advanced Medical Coding and Auditing shows how to code for services such as medical visits, diagnostic testing and interpretation, treatments, surgeries, and anesthesia. Real-world cases (cleared of any patient identifiers) takes your coding proficiency a step further by providing hands-on practice with physician documentation. With this guide, you'll learn to pull the right information from medical documents, select the right codes, determine the correct sequencing of those codes, and properly audit cases. - Real-world patient cases (cleared of any patient identifiers) simulate the first year of coding on the job by using actual medical records, allowing students to practice coding with advanced material. - UNIQUE! Evaluation and Management (E/M) audit forms include clear coding instructions to help reduce errors in determining the correct level of service. - More than 150 full-color illustrations depict and clarify advanced coding concepts. - From the Trenches boxes highlight the real-life experiences of professional medical coders and include photographs, quotes, practical tips, and advice. - NEW! Coding updates include the latest information available, including 2022 code updates when released. - NEW! Coverage of CPT E/M guidelines changes for office and other outpatient codes.
Take your first step toward a successful career in medical coding with guidance from the most trusted name in coding education! The bestselling Buck's Step-by-Step Medical Coding is a practical, easy-to-use resource that shows you exactly how to code using all current coding sets. To reinforce your understanding, practice exercises follow the explanations of each coding concept. In addition to coverage of reimbursement, ICD-10-CM, CPT, HCPCS, and inpatient coding, an Evolve website includes 30-day access to TruCode® Encoder Essentials. No other book so thoroughly covers all coding sets! - Theory and practical review questions (located at the end of each chapter) focus on recalling important chapter information and application of codes. - A step-by-step approach makes it easier for students to build coding skills and remember the material. - Learning objective and glossary review questions reinforce student understanding of key chapter concepts and terms. - 30-day trial to TruCode® Encoder Essentials gives students experience with using an encoder (plus access to additional encoder practice exercises on the Evolve website). - UNIQUE! "Real-life" coding reports (cleared of any confidential information) simulate the reports students will encounter as coders, and help them apply coding principles to actual cases. - Online activities on Evolve provide extra practice with assignments, including coding reports. - More than 450 illustrations help in understanding the types of medical conditions and procedures being coded, and include examples taken directly from Elsevier's professional ICD-10 and HCPCS manuals. - UNIQUE! Four coding-question variations — covering both single-code questions and multiple-code questions and scenarios — develop students' coding ability and critical thinking skills. - UNIQUE! Coders' Index in the back of the book makes it easy to quickly locate specific codes. - Official Guidelines for Coding and Reporting boxes show the official guidelines wording for inpatient and outpatient coding alongside in-text explanations. - Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information. - Valuable tips and advice are offered in features such as From the Trenches, Coding Shots, Stop!, Caution!, Check This Out, and CMS Rules. - Sample EHR screenshots (in Appendix D) show examples similar to the electronic health records students will encounter in the workplace. - NEW! Coding updates include the latest information available, promoting accurate coding and success on the job. - NEW! Coverage of CPT E/M Guidelines changes for Office and Other Outpatient codes.
Master coding concepts related to medical necessity and report compliant codes for your services. Revenue loss, rework, payback demands—how much are medical necessity errors costing your practice? And that’s to say nothing of potential civil penalties. Get medical necessity wrong and it’s considered a “knowingly false” act punishable under the FCA. Stay liability-free and get reimbursed for your services with reliable medical necessity know-how. AAPC’s Coding for Medical Necessity Reference Guide provides you with step-by-step tutorials to remedy the range of documentation and coding issues at the crux of medical necessity claim errors. Learn how to integrate best practices within your clinical processes—including spot-checks and self-audits to identify problems. Benefit from real-world reporting examples, Q&A, and expert guidance across specialties to master coding for medical necessity. Learn how to lock in medical necessity and keep your practice safe and profitable: Avoid Medical Necessity Errors with CERT Smarts Rules to Improve Provider Documentation Denials? Pay Attention to Procedure/Diagnosis Linkage Nail Down the Ins and Outs of Time-based Coding Expert Guidance to Fend Off RAC Audits and Denials Beat E/M Coding Confusion with Payer Advice Improve Your ABN Know How with This FAQ
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CPT(R) 2022 Professional Edition is the definitive AMA-authored resource to help healthcare professionals correctly report and bill medical procedures and services.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.