How to Interpret the SDoH Assessment Appropriately

2024 brought new HCPCS codes that Medicare, Medicare Advantage and some 3rd-party Commercial plans that they will now pay for. One of those codes is the G0136; that is the Social Determinate of Health (SDoH) assessment. It is not an add on code, but a stand-alone assessment.

G0136 defined as “Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.”

Again, G0136 is not a screening tool that should be used on all Medicare patients at office visits or annual wellness visits.

It is an assessment, not a screening. The assessment is performed at a visit after the physician/NPP has seen the patient and decides that it is necessary. And, if problems are found, follow-up is required. See CMS 2024 Final Rule citations below.

From the Final Rule, they do expect that a practitioner who furnishes the risk assessment would “… at a minimum, refer the patient to relevant resources and take into account the results of the assessment in their medical decision making, or diagnosis and treatment plan for the visit.” p.358 Final Rule.

CMS also, was clear that this is not a screening, and it requires physician follow-up.

“We reiterate that the SDoH risk assessment code, HCPCS code G0136, when performed in conjunction with an E/M or behavioral health visit is not designed to be a screening, but rather tied to one or more known or suspected SDoH needs that may interfere with the practitioners’ diagnosis or treatment of the patient.” CMS Final Rule, goes on to say, “An SDOH risk assessment without appropriate follow-up for identified needs would serve little purpose and we continue to believe that follow-up or referral is an important aspect of following up on findings from an SDoH risk assessment.” p.346 Final Rule.

So here is my professional advice on reporting this new code:

The only time you would bill Traditional Medicare and/or Medicare Advantage Plans for the SDoH assessment, G1036, is when an SDoH need is suspected, identified, and a plan of care is needed to address these concerns. At least 5 minutes or greater is documented, as described in the code. The appropriate SDoH needs to be identified in the medical record documentation and reported with appropriate diagnosis codes from the ICD-10-CM categories, Z55-Z65. (linking Z13.9 encounter for screening would not be appropriate)

This assessment can be done on the day of an E/M service (99202-99215), not including code 99211. During the comment period, CMS was asked about the patient using an on-line portal rather an having the service done on the day of an E/M service. Because CMS believes that this is not a screening, but an assessment, it is to be used when the practitioner believes that the patient has unmet SDoH needs that are interfering with the diagnosis or treatment of an illness, so this needs to be an in-person assessment.

CMS did not finalize the requirement that the assessment must be done on the same day as one of these visits, but it seems likely that is when it will be done. They do not believe it will be performed in advance, via a portal, because it is not a screening. It is performed as an assessment based on the practitioner’s evaluation of the patient’s situation.

Also, it is important to remember that G0136 will be subject to cost sharing, (co-pay and deductible) unless it is done at an Annual Wellness Visit (AWV), codes G0438-G0439.

Here is the reimbursement breakdown:

  • Non-Facility total RVU is 0.57 = $19.80 (office)
  • Facility total RVU is 0.27 = $8.84 (hospital, SNF, CAH, etc..)

Some examples of SDoH factors (diagnoses):

  • Illiteracy and low-level literacy —> Low health literacy may require different or more extensive efforts with patient education (i.e. all verbal instruction because patient can’t read written instructions)
  • Inadequate housing —> Patient may lack refrigeration in their home so can’t be prescribed cold storage medications, so you have to prescribe something else. May have mold infestation so have to intensify management of their asthma.
  • Extreme poverty or Low income —> May not be able to afford medications or other over-the-counter type therapies/devices.
  • Disappearance and death of family member —> May decide to defer addressing some medical issues to prioritize providing emotional support for bereavement.
  • Child in welfare custody. —> May have to spend extra time educating new foster parent on medical management or on how to provide support care for medical condition

Even though CMS does not require a specific form or tool, a link was offered on page 346 of the Final Rule. This link was offered for CMS’ Accountable Health Communities tool and is below in references and resources.


Pre-Op Visits vs. Pre-Op Clearance Visits: Which Are Billable?

A question comes up often regarding billing for pre-op visits. Should we? Or shouldn’t we? There is conflicting published guidance on this question from different sources.

First, this depends on what you mean by “pre-operative visits”. Are you talking about a visit performed by the surgeon (or the surgeon’s QHP) or a provider not involved with the surgery? If the decision is made to perform the surgery during this encounter, whether initial or follow-up, then it is appropriate to report an E&M visit. If the surgery occurs on the same day or the following day, append modifier -57 to the E&M, as the decision for surgery modifier.

However, if the patient is coming in for a “history and physical”, or “pre-op” visit to obtain consent and answer questions the patient may have – this encounter is not billable, as it is included in the reimbursement for the surgery. In the RVUs for all surgeries, with a 90-day global period, there is pre and post-op work included for this encounter. It would be considered “double-dipping” and being paid twice. Many have the opinion that technically if this encounter happens 2 or more days before the surgery, you could bill it, but ethically you probably should not. I would disagree.

There is no CPT code for a non-billable H&P encounter. Some providers choose to use 99024 to track the frequency and the associated ICD-10-CM codes for these non-billable services. Others use a code they have created, such as pre-op as a placeholder for these encounters, when their EMR allows for it, with no dollar figure attached. Other practices don’t track these encounters, and may not enter them into the practice management system at all.

Now, let’s look at a “pre-op clearance” or surgical clearance encounter, that would not be done by the surgeon or the PA/NP practicing under the surgeon. A surgical, pre-op clearance is where a specialist (i.e. Cardiologist or Internal Medicine physician), or PCP, clears the patient for surgery. For instance, if a patient with CHF (congestive heart failure) is scheduled for a total right knee replacement, under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient’s cardiologist. The cardiologist is not performing the surgery, and most likely follows the patient for this condition, therefore, the cardiologist will not be paid for any services included in the global package. So, the cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter.

These guidelines are in ICD-10-CM General Guidelines, Section IV item M “Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation” So in the hypothetical case mentioned above, the ICD10-CM codes would be Z01.810, M17.11, I50.9

Another scenario comes up, that many coders and physicians attempt to code as a pre-op visit, because of the hospital administrative mandate, but you have to determine what the visit is for.

Example: Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer: No, the H&P in this case is not a billable visit. This question comes up often and was addressed by AMA CPT® Assistant® in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package.

Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional questions. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT® Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT® says once the decision is made to proceed with surgery, the subsequent visits related to the procedure (e.g., an H&P, getting a consent form signed, answering questions) are included in the 90-day surgical package. However, in some cases, a patient may be a candidate for a surgical procedure but has several medical issues (such as cardiac disease, asthma, or Coumadin (anticoagulant adjustment needed)) that require a medical evaluation to determine if he/she is healthy enough for surgery. After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery. This visit may be billed as an E&M visit as the decision for surgery is just now being made.

One thing to remember is that utilizing mid-level providers in a surgery practice, such as a PA or NP to provide pre-ops, is not billable as they are considered the same specialty, and again, or not providing “medical clearance” but a pre-op to reiterate the original encounter discussion with the surgeon. There is no “medical necessity” for billing an administrative visit for duplicate information, to get home health referrals, prescriptions, or disability forms signed. You might have a cash charge, but billing this to an insurance company is a red flag.

Medicare has weighed in on pre-op visits as well:

15047. Preoperative Services

A. General

This manual instruction addresses payment for preoperative services that are not included in the global surgery payment. Sections 4820 and 4821 of the Medicare Carriers Manual (MCM) describe the preoperative care that is included in the global surgery payment.

B. Non-global Preoperative Services

Consist of evaluation and management (E/M) services (preoperative examinations) that are not included in the global surgical package and diagnostic tests performed for the purpose of evaluating a patient’s risk of perioperative complications and optimizing perioperative care. Medicare will pay for all medically necessary preoperative services as described in §15047, subsections C and D.

C. Non-global Preoperative Examinations

E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient’s risk of perioperative complications and to optimize perioperative care. Preoperative examinations may be billed by using an appropriate CPT code (e.g., new patient, established patient, or consultation).

D. Preoperative Diagnostic Tests

Tests performed to determine a patient’s perioperative risk and optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements.


You’ll notice a theme here. CMS is clear that pre-op, whether an E/M visit or diagnostic test, first has to be done to “evaluate the patient’s risk” for the procedure, and then it has to be “medically necessary”. A pre-op that does not address this, is not a billable service. It is a routine informed consent visit.

Prescription Drug Management: The Moderate Risk element of E/M Coding

Appropriate documentation of prescription drug management continues to be an opportunity for many physicians. Doctors need to know that simply adding the current medication list to the progress note is not adequate to include in the level of risk of a moderate visit.

Prescription drug management is based on documented evidence that the physician has evaluated medications as part of a service that is provided. Physicians should make a direct connection between the medication that is prescribed to the patient and the work that was performed on the day of the clinic visit, such as Stable hypertension; continuing Valsartan 10 milligrams, will refill for 4 months until next follow-up visit. Simply stating that the medication list was “reviewed” will not meet the definition of prescription management.

It would have been helpful if 2021 or the updated 2023 Documentation Guidelines, had been defined within the guidelines of Rx management to finally put to rest much of the ambiguity within the auditing world, but unfortunately, AMA did not. Many MACs have published guidance on this topic, and Noridian is pretty clear. Their guidance states: Prescription drug management is the initiation, continuation, discontinuation, or modification of any prescription medication. This does NOT include medications that are OTC and prescriptions that are ONLY prescribed for insurance benefits.

Keep in mind that patient convenience and reimbursement rules NEVER make such determinations. A keyword in the description that causes confusion is “management”. Oftentimes, coders/auditors hear the word management and infer that this would mean a longtime use of a prescription drug; but look up the word.

Management in healthcare is defined as the coordination and administration of tasks to achieve a goal.

How to determine Rx Management:

  • Did it require prescriptive authority?
  • Is the provider of record managing the Rx?
  • A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
  • Documentation of the prescription drug(s) that are being considered and the reason why they are being considered.
  • Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
  • The patient’s condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Again, simply stating in the medical record that the physician renewed a prescription “for a patient” or “continue meds” without further management discussion, does not meet the risk criteria in the Medical Decision-Making table, nor does it warrant an E/M service on its own.

Please remember that prescription drug management is based on the documented evidence in the record showing the provider has evaluated medications during E/M service as it relates to the patient. Simply listing medications that the patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place regarding those medications.

This information has been added to the Medical Decision-Making section of NGS Medicare, and many other MAC websites, have similar language on their Evaluation and Management Frequently Asked Questions web page.

Medical Acronyms You Need To Know!

In this climate of texting and wanting quick results for everything from ordering your lunch, to ordering medical tests, to attending a meeting with a speaker who uses a lot of acronyms that you are expected to know, let’s save some time and offer you a reference tool so you aren’t going to “Dr. Google” when trying to be present in your education as a medical professional.

Webinar Acronyms –Reference Tool

  • AAP – Advanced and Accelerated Payments (from Medicare)
  • ACO – Accountable Care Organization
  • ADR – Additional Documentation Request
  • APP – Advanced Practice Provider
  • AKS – Anti-Kickback Statute
  • APP – Cash Payment Applications
  • CAA – Consolidations Appropriations Act 2022
  • CARC – Claim Adjusted Reason Codes
  • CERT – Comprehensive Error Rate Testing
  • CF – Conversion Factor
  • CY – Calendar Year
  • CMS – Centers for Medicare and Medicaid
  • DOJ – Department of Justice
  • EOB – Explanation of Benefits
  • FCA – False Claim Act
  • FWA – Fraud Waste & Abuse
  • GAO – provides fact-based, nonpartisan information to Congress. Often called the “congressional watchdog,”
  • HHS – Health Human Services
  • HIMS – Health information Management Service
  • HIPAA – Health Insurance Portability & Accountability Act.
  • IDR – Independent Dispute Resolution (NSA)
  • LCD – Local Coverage Determination
  • MAC – Medicare Administrative Contractor
  • MedPAC – Medicare Payment Advisory Commission
  • MMA – Medicare Modernization Act
  • MPFS – Medicare Physician Fee Schedule
  • MSN – Medicare Summary Notice
  • MSO – Management Service Organization
  • NCD – National Coverage Determination
  • NPP – Non-Physician Practitioner
  • NSA – No Surprise Act
  • OCR – Office of Civil Rights
  • OIG – Office of Inspector General
  • PAYGO – federally mandated “pay-as-you-go” deficit control budget rules
  • PE – Private Equity (firms)
  • PHE – Public Health Emergency
  • ePHI – Protected Health Information (electronic)
  • POS – Place of Service
  • QHP – Qualified Health Care Professional
  • QPA – Qualifying Payment Amount (re: NSA IDR)
  • PRF – Provider Relief Funding
  • RAC – Recovery Audit Contractors
  • RARC – Remittance Advice Remark Codes
  • RCM – Revenue Cycle Management
  • RPM – Remote Patient Monitoring
  • RY – Reporting Year
  • SMRC – Supplemental Medical Review Contractor
  • TPE – Target Probe Educate
  • ZPIC/UPIC – Zone/Unified Program Integrity Contractor

Make sure you have this handy when you are needing to reference a particular regulatory guidance, speak to a physician, or listen in to an educational webinar. This will assist so you are not in the dark.

2nd Quarter 2022 Blog – Coding Corner Q&As

When you need answers to coding, billing, and reimbursement questions, who do you turn to? I am sure it isn’t Ghostbusters!. If you are a Coding Corner member or Executive member, you can get unlimited coding and billing questions responded to for a yearly fee. (See our Coding Corner Webpage for pricing.)

Here are a few Q&As over the last few weeks that have caught my attention and I believe could assist many in their workflows and coding processes. Enjoy!

When reporting RPM (Remote Patient Monitoring) codes, Holters, Event Monitors, etc, what is the best DOS to use on the claim?

Answer: “For RPM or any device monitoring, it is Best Practice to report the service when it is completed, as you might have to produce a report if asked. So the date that the patient returns the device or the date that the physician documents the final read is the best date of service to use for billing. You may find another payer that will allow billing on the date of hook up, but that would be rare.”

How do I code for Colonoscopy by snare and an “India ink” submucosal injection to lift the lesion?

Answer: 45385 and 45381-51 same polyp or lesion and not bundled as long as it is to help lift the lesion for removal and not to mark the space for a planned future procedure.

How do I code for a Mastectomy for breast size reduction for gynecomastia?

Answer: Look at 19300 for mastectomy for breast tissue removed for breast-sized reduction for gynecomastia, but if the breast tissue was removed for a reduction only, and there is no gynecomastia diagnosis, then use code 19318

How do I code a stent in the right common iliac and the left external iliac?

Answer: For bilateral lower extremity stenting, the CPT® 2022 Professional Edition gives us modifier direction of this scenario at 37221, and 37221.59. It seems like a -50 modifier would be more appropriate since this is a bilateral procedure, but CPT® overrules this coding application in the section for LE interventions.

How do I code a stent in the right renal artery and left renal artery?

Answer: 37236 and add-on code +37237 – there is no side-to-side or unilateral or ipsilateral offering. Only initial artery and additional artery.

How do I code for 99417 to add on prolonged care to the level 5 service?

Answer: If the physician reports a level 5, 99205, or 99215 for a Medicare patient and meets the “maximum” required time allowed for either code and then adds 15 minutes of clinical time, the provider can add the modifier G2212, which is a crosswalk to the add on code for prolonged services +99417. If the patient is a non-Medicare patient, CPT® allows for the minimum time of a level 5 to be met, and the additional 15 minutes, but we submit that Best Practices would be to follow CMS rules on this, as it makes more sense.

A patient had a TAVR procedure and had continued bleeding of the femoral artery, so a femoral artery stent was deployed. What code do I use for this service?
I see that the CPT® book states, “Codes 37220-37235 are to be used to describe lower extremity endovascular revascularization services performed for occlusive disease,” so I know that these codes do not apply since the stent was deployed for hemostasis. Is this a billable service?

Answer: I would recommend using CPT code 37236 for the placement of a stent (or stentgraft) when the device is placed to treat a bleeding vessel. Had this hemorrhaging vessel been somehow treated with coils, it would be coded as an embolization with CPT code 37244. If both coils and a stent were used to treat the same pathology, we would only code for the embolization. Code 37226 is for the placement of a stent in the femoral/popliteal region for the treatment of occlusive disease, while code 37236 is used when a stent or stentgraft is placed for the treatment of non-occlusive disease (bleeding, AVM, AV fistula, aneurysm or pseudoaneurysm [except in the iliacs where 34900 is used]).

On 1/8/2022 the patient returns for a scheduled skin biopsy for a lesion found at his initial visit.  The dermatologist evaluates the patient to decide if the patient has a preclusive history or allergies, to decide if the patient can tolerate the procedure, to ensure patient consent after education, and that the patient understands post-operative instructions.
Satisfied the patient can move forward with the recommended plan, the dermatologist decides to commence with the biopsy, which is performed with no complications. This visit took 15 minutes of the dermatologist’s time. Can an office visit also be billed here with a 25 modifier?

Answer:  No additional E/M is allowed on this return visit date, and the code billed is: 11102 with work RVU .66

Some E/M 2021 Rules Guidance

Question 1: I spent time reviewing charts and results before or answering questions after the date of the face-to-face encounter. Can I count this time in choosing my level of service?

Answer 1: No. When using time to choose your level of service, use only the time you spent on the date of service.

Question 2: Must I provide counseling or coordination of care to use time to choose my level of service?

Answer 2: No. The AMA does not require you to provide counseling or coordination of care to choose your procedure code based on the time you spent.

Question 3: If I do not document the date of the encounter, does this mean I cannot use time to choose my level of service?

Answer 3: You can still use the time spent face-to-face and for appropriate non-face-to-face activities on the date of the encounter to choose your procedure code. If documenting the service on a different calendar date, do not include the time spent documenting

To learn more about the Coding Corner Membership Options, go to

Answers to AMA/CPT® 2021 E/M Documentation rules and Errata Clarifications

Ever since the release of the new 2021 Evaluation and Management (E/M) guidelines for Office and Other Outpatient Services, ICD10University has been conducting numerous provider and staff educational training sessions through Webcasts, articles, and session spotlights on’s Talk Ten Tuesday live broadcast and podcast.  In this article, we will answer the Top 10 questions we continue to receive from our listeners and clients.

Can the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 documentation guidelines still be used?

You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E/M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215), only.

Do you have to document both total time and medical decision-making (MDM)?

The provider is not required to document both total time and MDM (medical decision-making). They can select whether total time or MDM best represents the work performed for each encounter. The provider should level their code based on the best circumstance for the encounter.

Discussed during our most recent EM 2021 Auditing Webcast, we polled our audience on whether providers thought the total time of the encounter or MDM best represented their work and the majority answered MDM. The case studies that were offered, also reflected that MDM was much easier to support higher levels of service than the time threshold.

We recommend that using “time” to level your encounter may be most appropriate for instances when the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions or counseling the patient on the best treatment plan takes an unusually long amount of time.

This is a “Best Practices” case scenario where basing code selection on time may allow you to report a higher-level visit that more accurately represents the provider’s work.

What is the best way to document total time?

To properly document total time, AMA instructs that the provider needs to document the activities performed and include a statement of the total time for the encounter.

Since you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination performed by ancillary staff), it is recommended that the provider includes a statement that the total time does not include the time spent performing other billable services. (e.g., the skin tag removed from the patient’s right armpit took 16 minutes that was not included in the total time of the visit, and was billed separately).

A frequent question our ICD10University educators have received is if it is required to document the time increments associated with each activity (for example, 5 minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time must be documented.

However, if your encounter is ever audited by a payer, it is recommended that your statement does include specific services with the total time spent to support your time as a qualifying leveling option.

If you are coding based on the total time, does the time a medical scribe spends documenting in the electronic health record count?

No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E/M code. We are also often asked if you can count resident time.

The answer is “no” as well.

The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching or supervising physician.

Can you count the order of a test that is interpreted and billed by the provider?

If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. For example, your provider orders a chest x-ray and an EKG during the face-to-face encounter, and bills for both of those services. They cannot count towards the Data Points under the MDM nor can you count the time to order or perform those services, as they are “separately reported”. There is no double-dipping.

The AMA’s technical correction (Errata) states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.

Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level.”

What this means is that if your provider reviews an x-ray for example that was taken in the ER and sent over for review by your physician with the patient, and the physician just went over the results with the patient, then you would count this “review of a unique test” under Cat 1 of the Data Points Element.

On the other hand, if this review included a more detailed, documented interpretation of the film by your physician in determining the next step of care, and again, well documented (not necessarily a formal interpretation), then this could be considered under Cat 2 of independent interpretation of a test performed by another provider that you did not separately report.

Can you count the order of a test on one date of service and the review of the same test when the patient returns for the next encounter?

No. You can count the ordering of the test during the visit when it’s ordered, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order, again AMA considers this double-dipping. It will be a challenge for auditing and CDI staff to determine when the test was ordered and reviewed to make sure credit is given at the appropriate encounter.

This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results, even though at some point the patient will be given the results.

Another typical scenario is the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests because they were ordered after the patient was seen and the order was not counted as data at the previous visit.

Can the physician include ordering preventative services tests like screening mammograms or screening colonoscopies for age-appropriate patients, in their MDM risk or in the “time” factor when leveling an encounter?

No. Per AMA and NAMAS, unless the testing has a direct bearing on “problems addressed” then simply adding or ordering preventative services that do not factor into the MDM of a problem-oriented visit, are not counted or time or MDM elements.

When a specialist sees a patient and sends a note back to the referring provider (PCP) is this considered a “Discussion of management with an external provider” under the Category 3 Data Point element?

No. CPT® Errata clarified what “discussion” means:

“Discussion: requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange.

The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).”

Now in saying that, the AMA direction for 2021 has been that to include any MDM elements or time elements that the work has to be on the same date as the “face-to-face” encounter; so this seems to be an exception. A little advice here would be to include this exchange if it is on the same date so that the record is not left open to wait for a return call back from the external provider.

When reviewing an external note, does each test and progress note count separately?

No, all the information from the unique source would be counted as one Data Element under Cat 1. This is clarified in the technical corrections released in March 2021 by the AMA: A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

When a patient requires a translator during their encounter, can this be counted as an “Independent Historian” under Cat 2 for low MDM or Cat 1 for moderate MDM?

No. Use of a translator does not count for independent historian since the patient is still giving the history.

However, if using “time” to level your visit, include the extra time it took to use a translator if that factored into a longer encounter. If the provider is the translator and extra time was not needed, then this would have no bearing on MDM or time.



CPT ® AMA Errata – Corrections 2021 5.3.2021

Modifier 22 Letter

As promised, below is my Modifier 22 Letter to assist in appealing claims: when the procedure or surgery was an “increased procedural service” and the reimbursement on the fee schedule does not account for the extra work, time, and difficulty.

Modifier 22 Letter (PDF Format)

What is a Remote Coder?

A career as a remote coder allows you to work remotely in the healthcare field and use your computer skills to access what you need to fulfill the job requirements of an onsite coder or billing professional.

Remote medical coders are typically set up through their employer’s/medical practice’s IT department to access the patient medical records remotely and the practice management software for billing and coding. Most tasks are data entry input related, but many remote coders that work outside the healthcare facility, typically from home, have additional tasks beyond the data entry of codes, and some employers do ask that the remote coder be onsite at least 2-4 times a month.

Successful remote coders will need to be attentive and pay close attention to details to avoid making mistakes. For those working from home, who can set their own hours, will also need to be disciplined and focus to stay on track to meet deadlines. The table below gives you and idea of the educational requirements for most remote coders.

Degree Required Associates degree common, or coding certification equivalent
Education Field of Study Health Information Technology (HIT), Revenue Cycle Management (RCM) or Professional and/or Facility Coding
Certification Most healthcare employers require a “coding certification” of some kind to prove experience in the field of coding, billing and reimbursement, and health IT**
Key Responsibilities Use ICD-10 and CPT codes corresponding to various diagnoses and procedures and enter them into medical software, keep records, insurance claim submission and follow up.
Job Growth (2014-2024)* 15% (for all coding professionals, medical records and health information technicians)
Median Salary (2017)* $37,110 (for all medical records and health information technicians)
$41,500 (for most coding professional remote positions with minimum 3-years experience)

*Source US Labor Statistics

** See below for Certification options

If you want to get “certified” as a coder (there is not a specific certification for remote coders), and I highly recommend you do, there are many options. For hospital facility coders, AHIMA (American Health Information Management Association ~ ) has several certification options, such as CCS (Certified Coding Specialist), RHIT (Registered Health Information Technician) and CCA (Certified Coding Associate) to name a few.

The AAPC (American Academy of Professional Coders ~ ) has physician based certifications, also known as “pro fee” coding certifications such as the CPC (Certified Professional Coder) and AAPC offers specialty certifications in areas like, Cardiology (CCC), Interventional Radiology (CIRCC), E/M coding (CEMC) and more. There are other certification options from Board of Medical Specialty Coding (, QPro formerly PAHCS (

Getting Started

Although the implementation of remote coding can be straightforward and seemingly easy to implement, you need to address a number of issues before sending coders home. These included:

  • developing telecommuting policies/procedures
  • human resource considerations
  • departmental process changes
  • Internet training
  • hardware/software evaluation
  • remote access to other systems

By the Rules: Telecommuting Policies/Procedures

Before implementing a remote coding program, ask ALL of the workers who will be working at home to sign a written telecommuting agreement. This establishes expectations for everyone involved, including managers and coders who will have very little direct supervision. It also establishes what the coders can expect from support and management staff.

The agreement should address issues such as:

  • defining telecommuting as a management option rather than an employee benefit
  • expectations relative to confidentiality issues
  • productivity issues
  • ownership issues
  • time frame for working at home
  • on-site availability
  • potential for cancellation of the entire program
  • reference materials and HIPAA regulations

If all of these issues are outlined at the start, there will be much less confusion, which will contribute to the program’s overall success.

To recognize and reinforce the importance of the confidentiality of the online record, a separate confidentiality agreement should be developed and incorporated. This document should address the office location within the home, the need for a separate secure location that will not be accessible when the coder is not working, the security of the information on the PC (and a computer that no one in the family has access to), and the need to sign off the application when the coder is not physically in front of his or her PC. Once the employee has reviewed and signed this agreement, there should be no questions regarding expectations about confidentiality and security.

Check List before you go remote:

Before implementing a remote coding system, here is a sample of questions to ask:

Human Resource Issues:

  1. Will coders be paid per chart or hourly?
  2. Will O/T be paid?
  3. Will any incentives be built into the program for productivity bonuses?
  4. How will coders report hours worked or number of charts completed?
  5. How do you hand sick time or vacation time?
  6. Will this be a W-2 employee with standard benefits or a 1099 contract worker?


  1. What types of charts will you scan?
  2. How will you accomplish scanning. Will this require an onsite FTE or will you be able to incorporate the process into an existing onsite employee’s daily workload?
  3. Will the scanner’s responsibilities be strictly clerical?
  4. How much prep work is needed to can, and how available is this employee to the remote coder?
  5. What volume will you be scanning?
  6. What charts will be coded on site vs those scanned?

Departmental Processes:

  1. Will all of your remote coders work at home full-time? Or will you try to blend in-house work versus the part-time work at home coder?
  2. How will you make sure that any loose material (i.e. lab results, path reports) that appear days after discharge or encounter get added to the scanned chart needed for coding purposes?
  3. If using charge capture forms who is responsible to get that to the remote coder?
  4. How will physician questions and queries be handled?
  5. Who will be in charge of quality control, compliance and answering coding questions?
  6. Will the remote coder be given a separate phone line to address patient questions on insurance billing and/or statements?


Being allowed the opportunity to be a remote coder, and not have to commute, deal with weather or traffic, office drama, coming in sick, etc, is a privilege not a right. If you are given the opportunity, it is up to you to respect the process and make sure you have what it takes to be a successful remote healthcare professional.

How to break into the Healthcare field as a medical coder

As the population ages, the need for medical coders is growing. The Bureau of Labor Statistics (BLS) expects this field to grow by 21% through 2020, a rate much higher than an average healthcare industry job. Breaking into the medical coding business is not difficult, especially with the demand for skilled coders so high.

Because coding is such a detail-oriented position and the coder’s work affects nearly every area of a medical practice, a novice coder can be quickly overwhelmed. When beginning a medical coding career, there are several tips to make the job easier and make your work better.

Learn the specialty

New medical coders often come out of a generalized educational program. This is a good foundation, but if you are working in a specialized practice, such as a radiology firm, or cardiology or orthopedic surgery, you most likely will need to dig deeper to understand some of the subtle coding nuances.

It is common for office procedures to carry multiple codes, and many times the office staff takes for granted that you know what those procedures and codes are. In a training course I was conducting last week, we had both the seasoned coders and the new or potential new coders that were moving from Med Recs to coding, and the seasoned coders had lots of questions on things they already had a point of reference on, but I noticed the new staff had nothing to say. I know part of that silence was because they were taking it all in, but part was because they really didn’t understand the concepts.

Spend time with the practice manager learning about the flow of the office and standard procedures so that you do not miss any codes that could prevent the office from being paid properly.

Look at previous coding

Pull previous superbills (or the EMR patient ledger) and claim forms for the most standard office procedures to see how they have been coded in the past.

Do not assume the codes are correct; review the procedures done against the medical record and perform a mini-audit to see if you would code the record in the same way. This often gives you a solid idea of normal office flow and procedure. Note any discrepancies and discuss them with the practice manager.

Review the explanation of benefits

Review all contested or unpaid explanation of benefits (EOBs) to see if a coding error is to blame. Often transposed digits or simple coder error created the problem. Fix the error and resubmit the record for payment.

Discuss large-scale, unpaid EOBs with the billing and office staff to ensure that you are all working as a comprehensive team to get every procedure paid as quickly as possible.

Coding materials access

Online access to CPT and ICD-10-CM coding books and materials is often included with your school textbook purchases; keep both the books and any online access codes in a safe place so you can bring them to your job. Having quick, reliable access to these materials will help you save much time and frustration as you are starting a new coding position.

Make these books your own by using highlighters for language within a code, tab areas that you frequent (out of order sequenced codes), make notes alongside a code that you are not familiar with but see often, and little notes to yourself as to remind what is correct and not correct, e.g. (99152 Moderate sedation- Propofol no, Midazolam/Versed yes).

Whatever helps you best understand and remember, do it. It will help you later if you decide to take your certification exam and on the job.

Salary information for medical records and health information technicians

Medical records and health information technicians earned a median annual salary of $38,040 in 2016, according to the U.S. Bureau of Labor Statistics. On the low end, medical records and health information technicians earned a 25th percentile salary of $29,940, meaning 75 percent earned more than this amount. The 75th percentile salary is $49,770, meaning 25 percent earn more.

In 2016, 206,300 people were employed in the U.S. as medical records and health information technicians. Only a fraction of this number had actual “certified” personnel doing the job.

Starting pay and pay by experience

According to a salary survey conducted by the American Association of Professional Coders, the average starting salary for medical coders was around $33,000 per year in 2012 – a figure which hadn’t changed significantly since 2008.

However, the latest round of statistics showed that salaries increased quickly since 2012, and the most recent figure for a starting medical coder in 2016 was $41,000. The same salary survey reveals that coders average about $47,000 after five to nine years on the job and can hit $50,000-$65,000 per year with between 10 and 15 years of experience. Those with over 15 years of experience averaged just over $60,000 per year.

Of course, there are other factors that determine what coders can expect to be paid.

Pay by region

Across the country, the AAPC found that all coders made an average salary of $47,870 per year. However, salaries vary considerably by region. The lowest average salary, $41,709 per year, was reported in the East South Central states.

Those in the West North Central states averaged $44,464 per year, and coders working in the Great Lakes region reported an average salary of $45,258. The highest-paying regions for this occupation were New England, at $51,382; the mid-Atlantic, at $52,505; and the Pacific region, at $56,980.

Pay by level of education

As of 2013, the AAPC reported that coders who do not have a college degree earned an average of $41,066 per year. Those who held a postsecondary certificate aka coding certification or associate’s degree – who made up over half of all respondents — reported an average salary of $45,941 per year. Those who held a bachelor’s degree earned substantially more at an average of $54,266.

Coders who held a master’s degree out-earned all other categories of education, with an average annual salary of $79,405. But to be fair, coders in those positions were either in administrative positions, consulting positions, had not only multiple certifications in coding but also at least 10-years experience.

Job outlook

According to the Bureau of Labor Statistics, job prospects for medical coders, medical billers and other health information technicians should be good through 2020. The bureau expects these jobs to grow at a rate of 21 percent, 11% higher than the average growth rate for the American economy. However, the AAPC found that about 23 percent of those holding entry-level credentials reported struggling to find a job in 2016.

Remember, the job does not come to you. You go to it. How do you do that? Start cold calling practices. I know it is the most glamorous way to grab that coding job, but some practices just do not have the time to post a job on Monster, or on a job fair website. Also, those sites tend to weed out good candidates, since they only assess what is on paper. Next, put yourself out there.

Take in-person coding workshops to network, go to AAPC and AHIMA chapter meetings and network, choose to start in a different department (billing or medical records or even front desk) and then work your way into the coding position. Once the practice sees you are overqualified for your position, you could open a window to move up, or you could decide you like a different branch of the medical office position.

Lastly, especially on social media, be smart. Complaining about your lack of job or how a certification entity hasn’t helped you only gets you noticed as a complainer that is waiting for that big break. It also shows a potential employer you have limited skills of propriety.

You don’t think physician practices and hospitals are looking at LinkedIn, Twitter, Facebook or Instagram? Think again.

I love Instagram, and Twitter, and have had more business generated through social media reach than ever before. Also, write articles and write a lot. A published author opens so many doors for employment because you now have name recognition. Write about what you know. AAPC, AHIMA, Advantage Health to name a few, are always looking for accomplished writers on the topic of healthcare. Oh and grammar counts.

Everyone has to start somewhere. There is no elevator to the top floor coming off of a new certification or a decision to be a coder. But you can do it if you have the right mindset and the right understanding of what it takes. Good Luck!