Coding Tip Corner: December 2024

As we come to the end of another year, here are four key coding reminders for offices to focus on in 2025!

• Always document thoroughly to support the chosen code level.
• Evaluation and Management codes should be based on the complexity of the visit.
• Be sure you are using the most current coding guidelines. (Remember, codes can change anytime, but most often change in October and April.)
• Focus on the accurate documentation of history, examination findings, medical decision-making, and any relevant factors to justify the level of code selected.

An important code reminder for the coming year: A CVA is no longer coded as a CVA with the I63 code upon discharge of the patient from the hospital. The appropriate code once discharged from the acute care hospital is for any sequel caused by the CVA.

Social Determinants of Health are proving to be an area of interest for recent audits! A random check has shown it is an underdeveloped area in most practices. Many practices have space directly in the record to allow these to be captured, but few are utilizing this opportunity. If the space is being utilized, sometimes years go between asking the questions. This is a great way to determine if there are valid reasons why a patient may not be able to adhere to the medical treatment plan. HealthTeam Advantage has a Care Management Department that can help if a patient requires outside assistance.

Let us work together in 2025 to ensure your patients and our members have a healthier new year!

If there is a particular coding question you would like to see information on, please reach out to us at [email protected].

Enjoy the holidays, and take some time to recharge!