The podcast covered Terry Fletcher's top 10 most-asked coding and billing questions for July, spanning ICD-10, CPT, compliance, hospital, and specialty scenarios.
Key topics included proper diagnosis coding, billing for chronic disease, rules for teaching physicians and hospitalists, use of certain modifiers and codes, and documentation best practices.
Important reminders were given regarding new ICD-10 codes, compliance with coding guidelines, and risks of inappropriate upcoding.
No major business decisions were made; the session was educational and advisory for medical coders and billers.
Action Items
No specific due dates or owners were identified within the podcast transcript, as it was a solo educational episode. No action items to list for this session.
Top 10 Coding Questions and Answers
1. Coding for Unspecified vs. Rheumatic Heart Disease
If mitral valve regurgitation is documented without mention of being rheumatic or non-rheumatic, apply ICD-10 and AHA guidelines: single valve, unspecified or non-rheumatic = code non-rheumatic; single valve, rheumatic = code rheumatic.
For multiple valve disorders stated as unspecified or rheumatic, default to the rheumatic code.
Always follow official guidelines, support coding choices with rules, and avoid assumptions not backed by documentation.
2. Classifying Hypertension and Diabetes as Chronic Conditions
Chronicity requires documented duration (generally 3+ months) and/or evidence from medications/pharmacy records.
For new patients without onset dates, do not assume chronicity—ensure providers document appropriately.
New remission code E11.8 for type 2 diabetes goes into effect October 1, reflecting improved patient status after lifestyle/medication intervention.
3. Billing for Admission from ER to Inpatient (Same Provider)
If a provider evaluates a patient in the ER and then admits the same patient to inpatient for the next day's encounter, bill ER codes for the first day and only use subsequent hospital care codes (not initial codes) for the admission day.
This aligns with 2021 and 2023 ENM rules, as clarified in CPT guidance.
4. Teaching Physician and Resident Telehealth Billing
Residents can perform telehealth under the primary care exception, but only level 2 or 3 codes can be billed without the teaching physician present.
Time cannot be used to level the visit; only medical decision-making applies.
Audio-only telehealth no longer covered under the exception as of 2024.
Downcoding visits just to get payment is not allowed and can be considered a false claim.
5. Hospitalist Visits During Postoperative Period
Hospitalist visits focusing on postoperative management (wound care, surgery-related concerns) are included in the global surgical package and not separately billable.
Visits for unrelated conditions that require separate management can be billed.
6. Use of G2211 for Visit Complexity
G2211 should only be added when visit complexity is documented and justified by today's medical decision-making, not simply because the physician is the continuing care provider.
Blanket use of G2211 for every visit is not appropriate and may not be paid.
7. Leveling Consults with Time by Structural (Interventional) Physicians
Level 5 visits require documentation of 60+ minutes face-to-face with the patient (new) or 40+ minutes (established), with exact times and supporting activities detailed.
Medicare and auditors may downcode unsubstantiated time-based claims; beware of patterns of excessive high-level billing based on time.
Use CPT code 33361, with appropriate modifiers (Q0, 62), and list the clinical trial number for trial cases.
Bundled services (access, angioplasty, left heart cath, pacemaker, root injection) should not be reported separately; reference CPT and NCCI guidelines for inclusions/exclusions.
9. Coding Only Pertinent Diagnoses for Each Encounter
Only code diagnoses relevant to the current encounter; listing all past diagnoses, especially resolved or unrelated, may lead to clutter, payer audits, and accusations of upcoding.
AMA guidance stresses relevance and clarity in problem lists.
10. Billing 99401 (Preventive Counseling) with ENM by Orthopedic Physicians
Preventive counseling code 99401 is a standalone service and not to be billed in addition to ENM except when counseling is the only service provided and properly documented.
General advice given to every patient (e.g., exercise, weight loss) does not qualify; prevent macros and non-personalized notes from being used for billing.
Decisions
Follow ICD-10 and AHA official guidelines for coding unspecified cardiac valve disorders — even when the logic seems counterintuitive, use non-rheumatic if only one valve is involved and unspecified; use rheumatic for multiple valves or if stated.
Open Questions / Follow-Ups
Will CMS and other payers further restrict or alter G2211 payment criteria in 2026 and beyond?
Will there be further clarification from the AHA or CMS on chronicity documentation for hypertension/diabetes?
Suggested to always clarify “who told you” when staff cite unofficial coding or billing practices.