Background: Accurate clinical documentation is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. However, since coding rules and terminology differ from common clinical language, there is a risk that the clinical reality will get lost in translation. This is where clinical documentation improvement (CDI) programs come [...]

Background: On January 1st, 2023, the AMA released updated CPT E&M codes and guidelines. While there were welcome aspects to these changes – including removing need for an extensive physical exam and making it easier to capture prolonged service time – healthcare systems were left grappling with a need to quickly respond to these complex [...]

Background: For academic hospital medicine groups to thrive and be partners with their hospital systems, physicians must document and bill appropriately as a means of demonstrating their clinical value. Yet, many major academic hospital medicine groups may be unaware or receive little training for this very important skill set. Based on data from the Society [...]

Background: Professional billing is crucial for both division revenue and sustainable healthcare. However, provider knowledge on optimal billing for varied clinical scenarios is often lacking. Critical Care Current Procedural Terminology (CPT) Evaluation and Management (E/M) codes are often appropriate for Hospital Medicine (HM) providers to use when providing critical care services to patients during a [...]