New physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first significant changes to CPT® physical medicine and rehabilitation codes in two decades. The new tiered evaluation codes also introduce separate sub-heads for PT, OT, and AT evaluations, but groups them together. This will help coding and billing in clinics and facilities offering all three services.

According to WHO, every year, worldwide, millions of babies die within the first 28 days of life, and just as many are stillborn. Unfortunately, most stillborn babies and half of all newborn deaths are not recorded in a birth or death certificate. This lack of data prevents countries from taking effective and timely actions to prevent other babies from dying.

Payers and the Centers for Medicare & Medicaid Services (CMS) require that the medical chart documentation sent to support a claim contain a legible and timely signature. For medical review purposes, Medicare requires the author, using a handwritten or a valid electronic signature, to authenticate the services provided/ordered. Even if the coding is accurate but the document lacks a legible signature the entire note will be disregarded.

Guidelines have been released by The Centers for Medicare & Medicaid Services (CMS) to ensure that every patient’s health record contains quality documentation. The general principles which have been laid down by CMS for medical record documentation with regards to reporting of medical and surgical services for Medicare payment are as given below

In case a pregnant patient visits an obstetrician/gynecologist during the antepartum for a problem unrelated to pregnancy then a question often arises that can the provider bill separately for that visit, or is the service bundled into the maternity care? If the provider can bill, is it necessary to append modifier 24 “Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period to the E/M code?”