How To Increase Compliance and Reduce Coding Challenges in 2025

Staying up to date on the ever-changing regulations and requirements of coding and documentation can be challenging.

Here are some essential ways that everyone from clinical providers to coders,  billing and revenue staff,  compliance, and even IT personnel can use to help ensure that the organization as a whole operates in an effective, profitable and legally compliant manner.

• Update EHR systems

Each year the organization’s EHR system must be updated with the latest coding software to ensure that the most current codes are available for use on and after their effective date and any deleted codes have been restricted for use to only past dates. Typically, this involves a partnership between the IT department and the coding and/or compliance department to integrate the current updates to the EHR system.

ICD-10 coding updates must be available for use by October 1st each year and CPT code updates must be available for use by January 1st of each calendar year.

Outdated software systems can result in claims processing issues and improper coding which could impact reimbursement or trigger audits.

• Update ICD-10 Codes

ICD-10 updates are published and implemented each year on April 1st and October 1st.  October 1st is the annual update with new codes added, and existing codes revised or deleted. Guidelines are also updated and revised annually for October 1st. 

April 1st is a mid-year update and generally  includes far less changes, though sometimes the updates include corrections or revisions. It is essential to review the changes in advance of the annual update and provide education and guidance to all personnel involved in the coding process prior to the October 1st implementation of the codes. If there are documentation requirements associated with new ICD-10 codes make certain that clinical providers are aware of what is required to support accurate coding.

• Update CPT codes

The CPT Editorial Panel is authorized by the AMA  and responsible for maintaining the CPT code set. The AMA prepares for the annual update of CPT codes for release in the fall of each year preceding the effective date and implementation of the codes on January 1st.  CPT codes are added, revised or deleted based on review of the CPT Editorial Panel. Guidelines for CPT code sets may be updated as well in accordance with changes to the codes in each category and use of emerging technologies.

Category I vaccine products and Category III codes are typically “early released” on either January 1st or July 1st for implementation effective 6 months subsequent to their release.  Codes that are “early released” on January 1st are effective for use on July 1st and codes “early released” on July 1st are effective for use on January 1st; this allows time for their review and implementation.

 It is crucial that all changes to CPT codes and guidelines be reviewed well in advance of their January 1st implementation (or in the case of early release codes prior to their subsequent effective date). Education and guidance should be provided to all personnel involved in the coding process to ensure accurate coding is utilized regarding all changes.  Clinical providers should be updated on documentation requirements associated with code changes to ensure that details support the code requirements.

• Correct use of modifiers

Misuse of modifiers can result in overpayments, and lack of use can result in rejections, underpayments or delay in reimbursement.  Either situation can put an organization at risk.  Education should be provided to all coding, billing and revenue staff to ensure that modifiers are correctly reported and are supported by the documentation to mitigate risks associated with incorrect reporting. Many payors, as well as the OIG, regularly monitor and audit for modifier usage.

• Follow bundling rules

Everyone involved in the coding process should be provided with education on the risk of improper unbundling to individuals and organizations. Documentation must be supported by separate services to ensure that incorrect unbundling does not occur, and edits should be thoroughly checked prior to claim submission as a verification method. Incidental procedures should not be separately reported. Neither should inclusive procedures. Coders, clinical providers and any others involved in the coding process should be educated on what the coding guidelines are related to inclusive, bundled and separate services.

• Understand the differences between outpatient or professional and inpatient or facility coding

There is a difference between outpatient/professional coding and inpatient/facility coding. Typically, coding staff does either professional or facility coding. However, single-path coding has increased in frequency recently, whereby the coding staff codes for both the professional services and the facility services.

When the professional and facility coding are performed by different staff members they may not always align.  If claim reporting of hospital services for the physician and facility have discrepancies, then claims may be denied and/or reimbursement may be impacted.

Members of the revenue integrity or compliance department should oversee that there is communication and alliance with these services to ensure not only correct coding is reported but there is minimal impact to accurate and timely reimbursement.

• Audit for correct coding and documentation improvement

Whether an internal process is implemented for auditing of documentation and coding or an external audit service is contracted, it is essential that frequent oversight be performed.  Auditing should not be considered a punitive measure but rather one in which improvements can be made.  If there is documentation which is lacking in detail then accurate coding may not be achieved.  Likewise, if there are coding deficiencies due to a lack of understanding of coding guidelines, this could result in a negative impact on revenue or a risk due to improper coding.

• Education for coding improvement or CDI improvement

Audit results should be followed by education to provide feedback to both clinical providers as well as coders, billers, and revenue personnel so that improvements can be made. Provide support for audit findings with regulatory guidance for a better understanding of the requirements for detailed documentation and accurate coding.

• Stay up to date on regulatory changes which can occur outside of the regular coding updates

As stated earlier, coding and documentation requirements are constantly changing. It is crucial to stay updated by following regulatory entities such as the AMA, CMS, and HHS. Publications and releases should be regularly reviewed for the relevance of updates and/or changes to the individual practice, specialty, or organization.

• Stay updated on the OIG workplan

To mitigate risk to individuals and organizations, it is imperative that the OIG work plan be reviewed at least monthly for the areas being audited or areas deemed to be on the watchlist. These areas are the most crucial for proactive audits, which can uncover inadequacies and produce improvement if necessary.

Bonus Tip: Join KZA at our National Conferences to supercharge your coding and audit skills! Immerse yourself in the latest updates on Orthopaedics, ENT, General Surgery, and Spine Surgery. Learn from top-tier KZA consultants, stay ahead with cutting-edge coding guidelines, and earn CEUs to elevate your professional development. Engage in live Q&A sessions, dynamic discussions, and network with other professionals in your specialty. Don't miss this chance to enhance your knowledge and be part of the future of coding excellence!

Is your Coding Compliance 95%?

Did you know the OIG has set the accuracy rate at 95%? In every setting, documentation begins and ends with the physician. Medical coding audits are a significant part of maintaining compliance. According to the recommended OIG Compliance Plan for Physician practices, auditing and monitoring are critical to ensuring compliance.

At a minimum, every medical practice should conduct an audit of its coding and documentation annually. Clinical documentation should be reviewed continuously to ensure accurate claim submission and improve revenue along with documentation and coding.

Medicare, Medicaid, and Commercial payors consistently audit physician claims for office and hospital visits, surgical procedures, and ancillary services. Did you know that payors are auditing E/M services with procedures on the same date when using Modifier 25? Payment recovery occurs when services that do not meet the Modifier 25 definition of “Significantly Separately Identifiable.” All payors are performing recovery audits on a routine basis.

Since the guidelines changed in 2021, we have seen an E/M shift, with a significant increase in new patient level 4s (99204) billed. This makes it even more important to audit and monitor, as the higher-level E/M codes have proven to be a red flag. Are your higher E/M levels supported in the documentation and medically necessary? If you don’t know, you need an audit to see where you stand.

Ask yourself these five questions:

1. Are you certain you are audit-proof?

2. When was the last time you had an audit?

3. If a payor audited your coding and documentation tomorrow, would it pass?

4. Will your documentation stand up to payor scrutiny?

5. What parameters has your practice implemented to ensure your coding and documentation are compliant?

An audit can identify:

• Incorrect code selection

• Unbundling issues

• Missed billing opportunities (missed procedures or undercoding)

• Services that were billed but not supported with accurate medical record documentation

• Higher levels of E/M services billed incorrectly

• Incorrect modifier usage

• Diagnosis coding errors and incorrect linkage to the CPT/HCPCS codes

• Documentation deficiencies or discrepancies

Healthcare reimbursement continues to operate under numerous regulations and compliance requirements that depend on good documentation and accurate coding.  An audit will improve documentation, ensure compliance, and ensure your practice receives the appropriate reimbursement for services provided.

Now is the perfect time to seek an expert review. KZA consultants have a wealth of experience and have meticulously examined thousands of chart notes. Our extensive specialty coding expertise establishes KZA as a trusted partner for audit and education. We’re here to help you. Contact a Client Services representative at 312-642-5616 to schedule your audit today.

CMS Skin Substitutes

Where do providers stand on Skin Substitute Products?

CMS has delayed the final LCD coverage policies for skin substitute products for the treatment of diabetic foot ulcers and venous leg ulcers until January 1, 2026. The MACs initially proposed LCD L35041 to be released in April 2025 for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers.

This delay means that Medicare will significantly limit the number of products that are approved for Skin Substitute Grafts/Cellular and Tissue-Based treatment of diabetic foot and venous leg ulcers. The LCD offers over 200 approved products. Medicare has approved only 18 products stating there is either no literature found or insufficient evidence for use of these skin substitutes on diabetic foot ulcers or venous leg ulcers.

Approved HCPCS codes:

Diabetic foot ulcers (DFU):

• A2019, Q4101, Q4102, Q4105, Q4106, Q4107, Q4110, Q4121, Q4122, Q4128, Q4133, Q4151, Q4158, Q4159, Q4160, Q4186, Q4187, Q4203.

Venous leg ulcers (VLU)

• Q4101, Q4102, Q4106, Q4151, Q4186.

What can you do?

1. Contact CMS at CAGInquiries@cms.hhs.gov by November 1, 2025, with skin substitute study results, peer-reviewed publications, and high-quality results from public sources. CMS will send the results and publications to your local MACs to review to determine if revisions to the LCD are appropriate.

2. Contact KZA at info@kzanow.com for support to meet medical necessity in the current policy.

Source:

Will the Real Conversion Rate Please Stand Up?

ASN July 2018 
by Karen Zupko

Everyone agrees that it’s important to understand how many patients seen in consultation actually schedule surgery. Aesthetic surgeons measure their value on it, and patient care coordinators are rewarded for improving it. Nearly every aesthetic surgeon we talk with wants to know what is a “good” conversion rate.

The Details of Denials Matter

AAOSNow – Winter 2023 
by Karen Zupko

It is interesting how orthopaedic surgeons react when they see a denial report for the first time. They often react first with surprise, followed by a perplexed question: “Why didn’t anyone inform me about this earlier?”

Simple Patient Financing Solutions for Maximizing Treatments

Aesthetic Society News – Fall 2022 
by Karen Zupko

Many aesthetic practices and spas we work with offer patient financing—but you’d never know it. Either there’s nothing mentioned on the Web site or it’s like an Easter egg hunt to find the information. When scheduling, patients raising concerns or questions about fees—are rarely told that financing is offered. Many practices wait and discuss financing only after a patient is seen and wants to schedule. It’s big mistake.

CMS Updates Physician Assistant and Nurse Practitioner Billing

AAOSNow – May 2022
by Sarah Wiskerchen

In January, CMS introduced guideline changes to its Medicare reporting rules that impact PA/NP billing. These changes could require practices to modify how they report split/shared services. Previously, shared services were frequently reported in the name of a physician. Now, new rules determine who can report the services. Failing to comply with the new CMS rules will create compliance risks for physician practices.

Disclaimer: Full article requires AAOSNow login.

Commonly Asked Coding Questions in 2022

AAOSNow – March 2022
by Sarah Wiskerchen

In this column, KarenZupko & Associates addresses recently asked questions on coding for various orthopaedic procedures posed by orthopaedic surgeons, practice managers, and staff.

Disclaimer: Full article requires AAOSNow login.

Op Note Documentation Tips Every Surgeon Can Use

You’ve submitted, in a timely manner, correct Current Procedural Terminology® (CPT) codes to the insurance company for the procedure you performed. The payor’s explanation of benefits (EOB) or electronic remittance advice (ERA) shows a payment of $0! Now what? Typically, you’d send in the operative note, showing the description of the procedure you performed.

The operative note is not only a medico-legal and patient care document. It’s usually the only information a payor wants when there is a dispute about your reimbursement.

So let’s walk through some key elements of the operative report documentation.

Pre-operative and Post-operative Diagnoses

All relevant pre- and post-operative diagnoses should be documented, including underlying co-morbid conditions that you consider relevant for the procedure performed. If a pre-op diagnosis is no longer relevant, or changes intra-operatively, then state this in the post-operative diagnosis statement.

For example, if the tumor or lesion pathology is not known pre-operatively, it is acceptable to state “unknown” in the pre-op diagnosis. If the frozen section comes back positive for a malignancy, this could be stated in the post-op diagnosis area.

Surgeon

The primary surgeon for the procedure is listed as the surgeon. In the academic environment, this is the attending surgeon for the procedure.

Assistant Surgeon vs. Co-Surgeon vs. Assistant at Surgery

Not crystal clear on the difference? Here are some tips that describe the different surgical roles typically seen in a procedure.

Procedure(s) Performed

The procedures performed are listed in this area of the operative note, which is typically on the top half of the first page. We recommend using CPT terminology as much as possible, but not including codes in the operative note. Why? Oftentimes, the codes documented in the operative note are not accurate.

It becomes a compliance issue when the codes in the operative report do not match the codes billed on the CMS 1500 claim form. Medicare’s General Principles of Medical Record Documentation state the CPT and ICD-10-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. When a CPT code is documented in the operative report but not billed the CPT code billed is not “supported by the documentation in the medical record” as Medicare requires.

Indications for Surgery

This short paragraph, a couple of sentences, is very important as it provides the clinical necessity for the procedure being performed. It is also important to state any previous, related surgery on the same or different structure/wound, why patient is being brought back to the OR, or planned future surgery, as these are clues that coders use to support specific modifiers.

For example, a patient may require stages, of surgery to reconstruct an open wound which would warrant use of modifier 58 (Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period). Stating clearly that the staged procedures are prospectively planned, in this case, would tell the coder and payor that modifier 58 is warranted and the full allowable should be paid. All too often, when the planned nature of multiple procedures is not documented, a modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) is used, which generally results in a payment reduction.

Complexity

This separate paragraph is a must if modifier 22 (Increased Procedural Services) will be used to obtain additional payment. This information should summarize the added complexity that will be in the subsequent details documented in the operative note.  Don’t expect a payor to wade through the details of the operative note to try to figure out whether to pay you more. Make it easy for the payor to “feel your pain” of the procedure in a Complexity, or Findings at Surgery, paragraph.

Details or Description of Procedure

This is typically the lengthiest area of the operative note that describes the procedure(s) performed in great detail. Documentation should include, but not be limited to, induction of anesthesia, patient positioning, set-up and use of special equipment (e.g., stereotactic navigation, robot), specific brand name of any implant(s), which surgeon did what when more than one surgeon is involved, etc.

The details in this section of the operative note should support the procedures listed in the aforementioned Procedure(s) Performed area, which should also support the CPT code(s) reported for the procedure(s).

6 Essential Coding Rules Everyone Needs to Know

Current Procedural Terminology® (CPT) is a coding system that physicians and other providers use to bill for their services. While typically not taught in medical school, residency or other formal education arenas, providers are still expected to know how to properly code for services provided.

Here are six basic coding rules that apply to all specialties and that every provider, manager, billing, and coding staff must follow. Understanding the basics will help providers code accurately and reduce the risk of an audit or insurance company takeback or refund.

1. Do not report multiple CPT codes when a single comprehensive code describes these procedures. Doing so is called “unbundling.”

For example, there are codes that describe a tonsillectomy and adenoidectomy performed at the same operative session (42820-42821). It is considered “unbundling” if two separate codes are reported – one for the tonsillectomy (42825-42826) and one for the adenoidectomy (42830-42836).

Another example is use of the exploratory laparotomy code, 49000. An exploratory laparotomy is included in all other laparotomy codes; therefore, 49000 would not be separately reported. To do so is considered “unbundling” because the more comprehensive code includes the exploratory laparotomy.

2. Avoid “upcoding.” Do not report a “higher” code when a “lower” code is more accurate.

“Upcoding” oftentimes occurs when reporting Evaluation and Management (E/M) codes for office and hospital non-surgical services. If the documentation supports 99203 (new patient visit, level 3), it is considered “upcoding” if the provider codes the service as a higher level such as 99204 (new patient visit, level 4).

3. Remember that there are services integral to a CPT code. Refer to CPT guidelines and your physician specialty publications for more information.

CPT guidelines are not very specific about the services integral to a surgical procedure code. From an intraoperative standpoint, CPT states only the “local infiltration, metacarpal/metatarsal/digital block or topical anesthesia” is included. The assumption is that services normally performed as part of a single CPT code would not be separately coded.

The lack of specificity in CPT has led several physician specialty societies to publish their own guidelines for members and coders.

A good example is performing a lumbar discectomy with use of fluoroscopy for disc space localization. The American Academy of Orthopaedic Surgeons’ Code-X, as well as the American Association of Neurological Surgeons Guide to Coding, state that fluoroscopy is included in all open surgical procedure codes and not separately reported as shown in the table below.

Correct	Incorrect
63030 Lumbar discectomy	63030 Lumbar discectomy
	76000 Fluoroscopy

4. Access or exposure (e.g., approach), is included in all surgical CPT codes with one exception.

CPT codes describe complete procedures. The incision/exposure/approach to the level of the pathology is included in all surgical procedure codes and should not be separately coded. The American Academy of Orthopaedic Surgeons’ Code-X and the American Association of Neurological Surgeon’s Guide to Coding are examples of how physician specialty societies have specifically defined that the access or approach to the procedure is included in the CPT code.

For example, the endoscopic intranasal approach to a pituitary tumor is included in 62165 (endoscopic transnasal excision of a pituitary tumor). When the otolaryngologist performs the endoscopic intranasal approach for the neurosurgeon to excise the pituitary tumor, then each surgeon reports the same CPT code with modifier 62 (Two Surgeons). The exposure/approach is included in 62165, a stand-alone CPT code, and should not be separately reported with component codes as shown in the table below.

Correct	Incorrect
62165-62	Neurosurgery:
Endoscopic pituitary tumor removal (co-surgery modifier)	62165 Endoscopic pituitary tumor removal billed by neurosurgery
	ENT:
	30520 Septoplasty
	31287 Sphenoidotomy

Another example is in spine surgery. The approach, or access, to the spine is included in all open spine surgical CPT codes. For example, the retroperitoneal approach is included in 22558 (anterior lumbar interbody fusion) because the procedure could not be accomplished without it. Therefore, when the vascular or general surgeon performs the approach – which is included in 22558 – the code is appended with modifier 62 and reported by both the approach and spine surgeons. It is not accurate for the approach surgeon to report a code such as an exploratory laparotomy (49000).

One exception: the skull base surgery codes (61580-61616) are separated into approach (61580-61598) and definitive procedure (61600-61616) for the resection and closure.

5. The usual closure is included in all surgical procedure CPT codes.

What is the “usual” closure? Well, that depends on the surgical procedure code. All surgical codes include the direct, or primary, closure where the wound edges of the operative tract created by the surgeon are closed primarily at the same operative session.

In general, my simple rule applies: if you open it, you’re supposed to close it.

Some codes may have language that closure is not included. In those instances, closure is typically not performed because the operative wound size is small such as in 41110 (excision of lesion of tongue without closure).

The excision of benign (114xx) and malignant (116xx) skin lesion codes includes a simple, or single layer, closure. If the closure qualifies for an intermediate (12031-12057) or complex (13100-13153) closure, it may be separately reported with the skin lesion excision code.

6. A “scout” endoscopy, diagnostic service, or exploratory procedure is included in a definitive CPT code performed at the same operative session.

Another of my simple rules is, if you are coding for cutting it out, you would not code for diagnosing or finding it.

For example, if you are doing a laryngectomy (31360), then the scout laryngoscopy to assess extent of disease and landmarks (31525) performed at the same operative session is included in the laryngectomy code and not separately reported.

Arthroscopy Coding for Major Joints - Shoulder

AAOSNow – March 2018
by Michael R. Marks, MD, MBA

An accurate understanding of coding rules increases likelihood of receiving appropriate payment
Correctly reporting and billing for arthroscopy services is often confusing.

Last month, AAOS Now reviewed the knee arthroscopy codes and outlined the appropriate use of modifiers. This month, the topic is coding for shoulder and hip arthroscopic procedures.

Arthroscopic shoulder procedures
The traditional coding rule about the shoulder is to consider the joint as one compartment. Due to continuous efforts by orthopaedic societies, a two-compartment (intra- and extra-articular) viewpoint is gaining acceptance. As a result, a few coding rules have changed. Intra-articular structures include the labrum, the long head of the biceps, a Bankart lesion, and the humeral and glenoid articular surfaces. Extra-articular structures include the rotator cuff (RC), the distal clavicle, and the subacromial space.

In 2017, the Centers for Medicare & Medicaid Services (CMS) made a significant change to the extensive débridement code (29823). There are now three situations in which this code can be billed if the extensive débridement portion of the procedure is performed in a separate area of the shoulder joint. This is similar to coding for the knee, which also has distinct anatomic compartments. The applicable codes are:

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Dropped Leads. Why They Happened and What to Do About Them

ASN Winter 2016 
by Karen Zupko

After mystery shopping over 150 aesthetic plastic surgery practices through their websites and by phone, we've come up with a pattern of kerplunked leads.

New Physician Onboarding Checklist

by Cheryl Toth, MBA

Use this checklist to manage the orientation and onboarding activities for each new physician you hire. Ask for regular status updates – especially about the credentialing process. Items listed in each section are not necessarily in chronological order.

Build Better Patient Relationships, Faster, Using the FORD Method

ASN Fall 2014
by Karen Zupko

“How long will I have to stop running after surgery?”