§ From the team
Notes on clinical documentation, EMR workflow, and what independent practice actually looks like from the inside.
No marketing posts. We publish when we have something specific to say about charting, coding, or running a small clinic.
- 01Medicare
Can you bill an office visit on the same day as an annual wellness visit?
Yes, for Medicare, when the doctor also evaluates and manages a separate problem. Bill the office visit with modifier 25 next to G0438 or G0439, and tell the patient her usual share applies to that part.
Read essay - 02E/M coding
When do test results count as data for office visit MDM?
Count each unique test once, at the visit where it was ordered, and each outside source's records once. A metabolic panel is one test, not fourteen numbers.
Read essay - 03E/M coding
Does a prescription refill count as prescription drug management for E/M?
A refill counts when the note shows a decision: how the condition is doing, the choice to keep or change the medicine, and the follow-up. "Refill metformin" on its own is an order.
Read essay - 04claim denials
Fixable denials: the money you earned but never collected
Most claims pay the first time. The loss hides in fixable denials nobody has time to rework. Here is where one month of claims ends up, and how to shrink the leak.
Read essay - 05modifier 25
When can you bill an office visit with modifier 25 on the same day as a minor procedure?
Bill the office visit with modifier 25 when the note shows real work on a problem beyond deciding on and doing the procedure. Here is a joint injection note, line by line, and the claim it supports.
Read essay - 06AI
Payers run automated checks on your claims. Run yours first.
Payers now use automated rules that read the codes on your claim before anyone reads the note. Here is how to check for the same problems before you submit.
Read essay - 07AI
How do you bring an AI tool into a small practice safely?
Give the tool one narrow job, get six answers from the vendor in writing, and name the person who checks its work. Write down the number it should move, then check that number at 30 and 90 days.
Read essay - 08AI
Where the compliance line sits for AI coding prompts
New OIG guidance and three recent settlements show what regulators object to in coding prompts. Here is what that means for a small practice using AI.
Read essay - 09AI
What 2026 research says about AI scribes and your evenings
A spring JAMA study found AI scribes save some time in clinic but not after hours, and an Annals study found the drafts still need a careful read.
Read essay - 10ICD-10-CM
Can you code a rule-out diagnosis at an outpatient visit?
No. At an office visit, code the symptom, sign or abnormal result you know today. A diagnosis the note calls rule out, probable or suspected stays in the note and off the claim.
Read essay - 11E/M coding
Should you bill an office visit by time or by MDM?
Either one, chosen visit by visit. Time fits visits where counseling, record review or charting took the clinician's day; medical decision making fits visits where the decisions carried the weight.
Read essay - 12chart review
Can AI chart review prevent claim denials?
Yes, for the denials that start in the chart: codes that can't be billed together, a missing left or right, two codes that should be one, and a visit level the note doesn't support. Here's what to check and how to test a tool on your own denied claims.
Read essay - 13EMR overlay
Should a small practice switch EMRs to fix its billing and charting problems?
Usually not. Denials, notes that don't back the visit level and late-night charting follow you to a new EMR. Tools that work inside the EMR you already have fix them without moving a single chart.
Read essay - 14ICD-10-CM
Which chronic conditions belong on today's claim?
A chronic condition belongs on today's claim when today's note shows the provider checked it, reviewed a result for it, assessed it, or treated it. A condition that only sits on the problem list stays off.
Read essay - 15E/M coding
99213 vs 99214: what does the note need to show?
A 99214 needs moderate medical decision making in two of three areas: problems, data and risk. A 99213 needs low. Here is the same diabetes visit written both ways.
Read essay - 16AI scribe
Do you still need chart review if you use an AI scribe?
Yes. An AI scribe writes the note from the visit, and nobody checks the codes against that note until a claim comes back denied. Here's what slips through, and which tool a small practice should start with.
Read essay - 17chart review
What should you check before signing a primary care chart?
Check five things before you sign: the codes match today's note, no two codes contradict each other, every code that can name a side names one, each chronic condition shows today's care, and the visit level matches the note.
Read essay - 18ICD-10-CM
What's the difference between Excludes1 and Excludes2?
Excludes1 means two diagnosis codes can never go on the same claim, because both can't be true. Excludes2 means the conditions are different, so you code both when the patient has both.
Read essay - 19clinical workflow
What we mean when we say clinicians get their lives back
Primary care doctors see their last patient at 5:30 and close their last chart near 10. Much of that evening goes to making the record hold up for billers and insurance companies, and that's the part we're working to end.
Read essay