Author Archives: Gail Smith, MA, RHIA, CCS-P

About Gail Smith, MA, RHIA, CCS-P

Gail Smith, president of Gail I. Smith Consulting, is a nationally recognized coding educator. For most of her career Gail was an associate professor and director of the health information management (HIM) program at the University of Cincinnati and HIM program director at Cincinnati State Technical and Community College. Gail is a currently a consultant with a software company specializing in medical terminologies. Gail has authored several textbooks, including Basic Procedural Terminology and HCPCS Coding published by the American Health Information Management Association (AHIMA).   An advocate for advanced coder training, Gail is the author of several titles for Libman Education including CPT: Introduction to Procedural Coding and two courses on the unique challenge of CPT coding in the pediatric setting: CPT for Pediatrics and CPT for Pediatrics: Advanced Orthopedic Coding. According to Gail: “One cannot possibly teach every coding scenario a coder will experience in their career. That is why coding education needs to focus instead on how to arrive at an accurate and defensible code assignment. It is the difference between learning to fish, and being given a fish. If you learn to code instead of being given answers to memorize, you will be able to arrive at the complete codes more quickly and with greater confidence.”
Big Changes for E/M Codes in 2023

Big Changes for E/M Codes in 2023

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 […]

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Getting it Right: Knowing Enough to Challenge the Encoder

Getting it Right: Knowing Enough to Challenge the Encoder

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 […]

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CPT: Posterior Lumbar Interbody Spinal Fusion

CPT: Posterior Lumbar Interbody Spinal Fusion

CPT: Posterior Lumbar Interbody Spinal Fusion   CPT Coding for spinal procedures can be challenging. This LibmanLightbox™, by nationally recognized coding authority Gail I. Smith, MA, RHIA, CCS-P, takes a closer look at posterior lumbar interbody fusion (PLIF) codes and when it is appropriate to use the decompression add-on codes.    Short bursts of learning […]

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When Does a ‘Device’ Turn into a ‘Foreign Body’? CPT 2022 Offers a New Guideline to Answer the Question

When Does a ‘Device’ Turn into a ‘Foreign Body’? CPT 2022 Offers a New Guideline to Answer the Question

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 […]

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Skills and Attributes for a Successful Coding Career: Lessons from Martha Stewart

Skills and Attributes for a Successful Coding Career: Lessons from Martha Stewart

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 […]

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CPT 2022 Welcomes Revised Spinal Fusion Terminology

CPT 2022 Welcomes Revised Spinal Fusion Terminology

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 […]

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Kawasaki: COVID-19-related Illness in Children

Kawasaki: COVID-19-related Illness in Children

by Gail I. Smith, MA, RHIA, CCS-P As coding professionals, we listen to news stories with a “clinical ear.” COVID-19 has many mysteries but the most recent involves children and what is described as Kawasaki-like inflammatory disease that has a link to COVID-19. Kawasaki disease is characterized by inflammation of blood vessels that could potentially […]

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COVID-19: The HIM Professional’s Role in Ensuring Data Quality

COVID-19: The HIM Professional’s Role in Ensuring Data Quality

by Gail I. Smith, MA, RHIA, CCS-P As our country faces the COVID-19 pandemic, coding professionals have an important role to play capturing critical health data. Guidelines from the National Center for Health Statistics and CMS provide strict instruction to ensure consistent data collection. Coders take this responsibility seriously and both internal and external auditors […]

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COVID-19: Key Take-aways from CMS Guidance for Coding of Telehealth Services

COVID-19: Key Take-aways from CMS Guidance for Coding of Telehealth Services

by Gail I. Smith, MA, RHIA, CCS-P A Medicare Telemedicine Health Care Provider Fact Sheet was released by CMS on March 17, 2020. Link: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet CMS is expanding telemedicine benefits with a 1135 waiver that will pay for office, hospital and other visits furnished via telehealth starting with March 6, 2020 and lasting for the […]

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Changes to CPT for FY2020: What’s New?

Changes to CPT for FY2020: What’s New?

Hear nationally recognized ICD-10 expert and Libman Education course author Gail I. Smith, MA, RHIA, CCS-P, discuss Changes to CPT for FY2020: What’s New? in this free, brief presentation, an excerpt from Gail’s CPT® Code Updates for FY2020.   Master the Code Changes in the 2020 CPT Code Set CPT Code Updates offers detailed explanations of complex […]

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