Local Health Department Billing Manual

Coding and Medical Record Documentation​


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Accurate medical reco​rd documentation and code selection is a cornerstone of care continuation, demonstrating care complexity, compliance and reimbursement. This section offers general and Specialty-Specific Coding Guidelines.



Document TitleDateExpirationDescriptionSource
General
AdvancedMD-ebook-CPT:HCPCS-2024
​No date
​No date

​Advanced MD
Coding for Screening and Brief Intervention Reimbursement
Apr-2022​
No date​​SAMHSA

UnitedHealthcare Medicare Advantage Reimbursement Policy Update Bulletin: Oct 2023

Jan-2024


​No date

​United Healthcare


Evaluation and management- CMS coding instructions and additional references


​Jan-2024



No date

​Novitas


Electronic Submission of Medical Documentation (esMD)
​Sep-2023
No date​
​CMS

Apr-2023






​No date







Coding for Screening and Brief Intervention ReimbursementApr-2022 No date SBIRT Coding & Billing SAMHSA
Medical Documentation and checklists No Date No date Medical Documentation and Checklists Novitas
Ins and Outs of Behavioral Health Documentation AuditsMar-2022 No ate Behavioral Health documentation AAPC
https://www.samhsa.gov/sbirt/coding-reimbursementApr-2022 No date SBIRT Coding & Billing SAMHSA
USFHP tricare Outpatient Code Editor
No date​
No date​​JHHP
JHHC Medical Record Documentation Standards
​Mar-2014
​No date
​JHHP
Guidelines for Medical Record Documentation

​Jul-2018
​No date
​21 standard elements of documentation
​NCQA
Maryland Medical Record Retention and Release Guidelines

No date​
​No date
​State guidelines on keeping and releasing records
​MDH
E/M Services Guide MLN
Aug-2021​



​No date



​Medicare learning network guide to evaluation and management services
​CMS





Oct-2023


Sep-2024



​CDC







Sep-2023



​Sep-2024




​MGMA



CMS Coding Guidelines
Novitas Solutions Documentation Worksheet
No date​No date​​Novitas
The LCD Process
No date​
No date​​Novitas

Behavioral Health Integration Services

Jan-2023​​No date
​2023 changes to BHI
​​Medicare Learning Network
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00273110Jan-2023 No date 2023 Vaccine CPT Codes & Fees Novitas
CMS ICD-10-CM Guidelines Updates April 1 2023 FY23 (cms.gov)
Apr-2023​​Sep-2023

​CMS
​Jul-2023
No date​
​CMS

Jul-2023​
​No date
​CMS
Jul-2023​​No date
​CMS


Jul-2023​
​No date
​CMS
2024 ICD-10-CM Code Addendum - UPDATED 6.23.23
Jun-2023​​Dec-2023
​CMS

​Jun-2023



No date



​Medicare Learning Network


Comploying with Medical Record Documentation Requirements
​Jul-2023
​No date

​ICD-10-CM Coding and Reporting Updates for FY 2024
​No date
No date​​MGMA
Evaluation and Management
Proper Use of Modifiers 59, XE, XP, XS, & XU
​Feb- 2024
No date​​CMS MLN
CHI_SDOH_PIN_FAQ_2024

Jan-2024​

​No date

​CMS

CPT Assistant Back Issue Index-Winter 1990-December 2023


Jan-2024
​No date


​AMA

How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

​Jan-2024

​No date

​CMS MLN

Complexity Add-on Code G2211


Dec-2023

No date

​Noridian Medicare

Fact Sheet - Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits


Jan-2021


No date

​AMA


Evaluation and management- CMS coding instructions and additional references
Jan-2024​​No date
​Novitas
AAPC The Magazine - Create a 2024 Audit Plan for Success
​Jan-2024
​No date
​AAPC
2024 CPT Updates
​Dec-2023
​No date

​AAPC​
CPT 2024 Is Here!
​Dec-2023
​No date
​AAPC
Coder's Specialty Guide Pathology & Laboratory Vl I&II
Jan-2022​No date​​AAPC
Clinical Examples 2021 Office & Other Outpatient E/M Codes

















Jan-2021​


















No date



















American
 Academy of Child & Adolescent Psychiatry















CPT® Evaluation and Management (E/M)
Code and Guideline Changes

Mar-2022

No date

2023 E/M Updates

AMA

Get a Look at CPT® 2023 Code Changes.pdfDec-2022 No date AAPC
Get a Look at CPT® 2023 Code Changes.pdfDec-2022No date2023 E/M UpdatesAAPC​
Medical Decision Making Simplified
​Jan-2023
No date​​ASCO
Connecting Social Determinants of Health to ICD-10 CM Z Codes​ 
​Apr-2023
​No date

​ASCO
USING Z CODES: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes
​Jun-2022
​No date
​CMS

​Jun-2023


​No date



​Medical Revenue Cycle Specialists




​Jul-2023

​No date

​Advanced MD


Apr-2023​

​Dec-2023

​AMA



Aug-2023​

​No date

​AMA



​Jun-2023


​No date


​AMA



​Jun-2023

​No date

​AMA



Sep-2023



​Dec-2024




​Becker's
Healthcare


​CPT Editorial Summary of Panel Actions September 2023
​Oct-2023
Jan-2025​
​AMA
Impact of Vital Signs on Level of Service Billing
Oct-2023​
​No date
​AMA
The Problem List Toolkit
​Nov-2023
​No date

​Intelligent Medical Objects