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FDA Recalls
Coding
E/M Coding Emergency Room Encounter with Surgery
If a Medicare patient is seen in the emergency department and then surgery is performed later that day or night, can the emergency department consult be billed with a modifier -57 along with the surgery? We have been under the impression that, at least in the office, the visit to decide to do the surgery is included in the surgical fee. Are we correct and does this apply to the encounter in the emergency department too?
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AI
AI Chat Histories and Medical Malpractice: A New Discovery Risk for Healthcare Providers
As artificial intelligence tools become more embedded in clinical and administrative workflows, a new legal question is emerging for healthcare organizations: Could AI chat histories be used as evidence in medical malpractice litigation?
Recent federal court decisions suggest the answer is evolving—and uncertain. For providers, that uncertainty creates real exposure.
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FDA Recalls
Coding
Surgical Coding Removing Hardware in Clinic
“I have an unusual situation that I am trying to figure out how to code. I had a patient return to the office in the global period after I performed a 1st metatarsophalangeal joint (MTPJ) arthrodesis. Although, the alignment of the fusion looks good, one of the non-locking screws advanced out of the bone and plate and started to tent the skin at the incision site at three weeks post operative. She is neuropathic and denied any trauma to the area. I removed the screw in the office with local anesthesia. Can I bill for unplanned screw removal in the office?”
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HIPAA
Getting ready for FIPS 140-3
Over the years, we’ve published several articles explaining what constitutes a breach and the steps to take if one occurs in your practice. Today, we’re focusing on “Safe Harbor” provisions—specifically, when an incident may not be considered a reportable breach.
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