Critical Care is the direct care by the physician or MLP for a patient with a high probability of imminent or life threatening deterioration in their condition. The physician makes complex decisions to assess, manipulate and support vital system function to treat organ system failure and/or to prevent further life threatening deterioration. Medicare states that...Read More

An NPP in the ED is defined by Medicare as either a nurse practitioner (NP) or a physician assistant (PA). The DEA uses the term “midlevel’s” (MLP). Some federal agencies refer to them as advance practice provider (APP’s).Read More

Laceration repairs are one of the most common procedures performed in the ED setting. CPT is based on three elements: length, location and complexity. Documentation should accurately reflect each of the 3 required elements in order to have the appropriate CPT assigned:Read More

E/M is based on three elements: History of present illness (HPI), Physical Exam (PE) and Medical Decision Making (MDM). Documentation should accurately reflect each of the 3 required elements in order to have the appropriate E/M...Read More

The U.S. Centers for Medicare and Medicaid Services dramatically changed the delivery of healthcare in response to the COVID Pandemic with the 1135 Waivers.  With Telehealth visits compromising up to 90 percent of some outpatient visits during the pandemic, the time has finally come to adopt this patient assessment modality.Read More

Effective April 1st, 2020, the 2020 ICD 10 CM, in an unusual off-schedule modification, published guidelines for appropriate coding of COVID-19 infections using the U07.1 code.  This code is effective for discharges and dates of service after April 1st, 2020.Read More