Modifier 25 remains one of the most audited—and most overused—modifiers in medical coding. But the problem isn’t just coding mechanics. It’s about appropriateness, credibility, and documentation.

Designed to represent a significant, separately identifiable E/M service performed on the same day as a procedure, Modifier 25 is too often applied automatically, like scotch tape slapped on to avoid an edit denial. When the documentation doesn’t support it—or when the service isn’t truly separate—misuse doesn’t just trigger denials. It invites deeper scrutiny and puts the entire visit under the microscope.

Terry breaks down why Modifier 25 is so frequently misapplied and shares her smart, reliable method for determining when it’s actually necessary. Listen to today’s CodeCast to learn how to protect your claims, your documentation, and your credibility.

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Many EMRs now embed ICD‑10 and CPT codes directly into the medical record. But is that advisable? The safest approach is still to let the documentation stand on its own. The content of the record should support the coding choices, and coders and auditors should base their work on the medical facts as documented. Codes can—and should—be applied only after the documentation is complete.

On today’s CodeCast episode, Terry explains that when providers insert billing codes into the note, the intention may be good, but the risk of contradictions or inaccuracies can outweigh any perceived benefit.

Should medical record documentation stand alone, without templated teaching language that was never meant to be included? Should codes appear in the record simply to give the impression of accuracy, rather than allowing the documentation to speak for itself?

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The post Who’s Doing the Coding — Providers or Coders? appeared first on Terry Fletcher Consulting, Inc..

When performing audits, the same macro statements keep appearing in progress notes: ambient AI scribing was used to create the documentation, and the note may contain errors. The pattern mirrors what happened when early talk‑to‑text tools rolled out. From a patient’s perspective—especially someone with little or no understanding of ambient AI scribing—this raises real questions about whether they truly understood what was used during their visit and what they were consenting to.

Terry breaks down this issue this week, drawing on an excellent article by Stephanie Allard, RHIT, to explore informed‑consent workflows, compliance expectations, and liability concerns surrounding Ambient AI Scribing.

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The post The Compliance Gap in Ambient AI Scribing and Informed Consent appeared first on Terry Fletcher Consulting, Inc..