Gail I. Smith, MA, RHIA, CCS-P

With Artificial Intelligence (AI) gaining ground every day, it is becoming clearer that hands-on training is essential for coders who are responsible for integrating the value of the AI coding support tools while ensuring accurate and defensible code assignment.

Hands-on experience is the essential bridge between the classroom and real-world coding. It transforms a coder’s theoretical knowledge of how the patient’s story is represented in codes into the practical skill of interpreting inconsistent documentation, resolving guidance and balancing accuracy with productivity.

In an era where AI is reshaping industries, deep specialized knowledge remains a cornerstone of success. AI is not a magic wand, it’s a tool. It can enhance efficiency, but it cannot replace the critical thinking, clinical understanding, and judgment that coding professionals bring to the table.

Epic (the top EHR vendor by market share) is planning on using AI to generate progress notes, create draft responses to patient questions, and assist with medical coding. This is one to watch.

UPDATE re: Capsule procedure 19370 with insertion of new implant (code 19325 vs. 19342) CPT Assistant, September 2022 confirmed that in cases of previous breast augmentation with an implant, code 19325, Breast augmentation with implant, would be used to report the replacement of an implant instead of code 19342, Insertion or replacement of breast implant on separate day from mastectomy.

Medical coding is complex and time-consuming, complicated by payer-specific billing rules, coding guidelines, and translating complicated clinical documentation into three distinct coding systems. Can AI help untangle the complexity of coding systems and reduce cognitive overload?

By Gail I. Smith, MA, RHIA, CCS-P In 2021, Evaluation and Management (E/M) office-visit codes changed significantly. The American Medical Association (AMA) listened to physicians’ concerns about the administrative burden associated with documentation requirements for the E/M codes and made changes to the methodology for code selection. The 2021 changes allowed the E/M services to be reported based on either time or medical decision-making. After the AMA announcement for changes to E/M Office codes, I had the opportunity to listen to a webinar when a representative from the AMA entertained questions about Evaluation and Management codes in CPT. One of

By Gail I. Smith, MA, RHIA, CCS-P Did you see this article? Another hospital paying major damages due to “unintentional and primarily software-generated” coding errors. Encoders and artificial intelligence are great technology with promises of increased productivity and “optimized” coding selection. But like any logical, consistent technology applied to a very human endeavor such as medicine, the technology can take a wrong turn and you end up out in the weeds with nonsense recommendations. Without a skilled human coder to review the answer the software delivers, you are reduced to hope, hope that the system is getting it right. What

By Gail I. Smith, MA, RHIA, CCS-P Guideline Part I: What is an Implant? There is a new guideline in the Surgical Guidelines for CPT 2022. CPT defines an implant as an object that is intentionally placed by a physician or other qualified health care professional for any purpose (e.g., diagnostic or therapeutic). This portion of the guideline seems straight forward, surgical implants (devices) are used in every operating room, numerous times a day. Guideline Part 2: What is a Foreign Body? The second portion of the guideline defines a foreign body as an object that is unintentionally placed (e.g.,

by Gail I. Smith, MA, RHIA, CCS-P Reprinted from December 2020 I gave up trying to be like Martha Stewart many years ago, but I still enjoy reading her magazine and adoring all of the beautiful photos of homes, food, and gardens. The Christmas edition is always my favorite. Last Christmas, celebrating 30 years, the magazine included a special feature where they highlighted “Lessons from Martha.” As I continued to thumb through the magazine, I found myself thinking that these lessons from Martha could also apply to coders. Martha’s photographer mentioned that “She is authentic, strong and curious.” I perked

By Gail I. Smith, MA, RHIA, CCS-P What is the difference between a spine level, interspace and vertebral segment? Anatomy drives the answer to that question but CPT terminology used them interchangeably for posterior lumbar fusion. This caused coding professionals frustration for many years. Help is finally on the way for 2022. Anatomy Review Anatomy 101 teaches us that the spine is made up of bones called vertebrae that are stacked on top of each other. Between each vertebra is a soft, gel-like cushion called an intervertebral disc. The space occupied by the disc is also called the interspace. Vertebral

By Gail I. Smith, MA, RHIA, CCS-P January 1, 2021 ushered in the biggest change in E/M coding since the 1990s. The new Office/Outpatient code descriptions, definitions and time as a key component were added to the code set. On March 9, 2021, AMA published an additional set of definitions and clarifications to the guideline document. The following is a list of content areas in the March 9 changes: Reporting a test that is considered, but not selected Definition of Analyzed Clarification of Unique Test Clarification of Discussion (between physicians, other qualified health care professionals, and patients) Definitions of Minor,

by Gail I. Smith, MA, RHIA, CCS-P Go to the web and search for a procedure, any procedure will do but type the phrase CPT code in the search box. Chances are you will receive advice from a variety of sources. You may think to yourself, that was so easy. The question becomes, can you trust this advice? While developing content for an upcoming advanced CPT training course, I was searching the web for resources related to a procedure. Among the responses was a coding recommendation supported by a comment: “we submitted this code and it got paid.” This type of