In this episode of the CodeCast Podcast, Terry Fletcher answers key medical coding and billing questions in a detailed Q&A session designed for coders, billers, auditors, and healthcare providers.

This episode covers E/M coding with minor procedures and when services can be billed separately, RTM (Remote Therapeutic Monitoring) for CPAP patients, CO-96 Medicare denials including what they mean and how to properly appeal, along with real-world coding scenarios and expert guidance to help improve reimbursement and reduce claim denials.

If you’re looking to stay compliant, optimize your coding practices, and better understand payer requirements, this episode delivers practical, actionable insights you can use immediately.

Be sure to subscribe to the CodeCast Podcast for weekly updates on medical coding, billing, and compliance.

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The post Top 10 Tuesday Medical Coding Q and A appeared first on Terry Fletcher Consulting, Inc..

You receive a payer inquiry questioning level 4 services… so you open the note and see:

“Patient here for follow-up. Doing well.”

That’s it.

Now you’re stuck defending a level of service that the documentation doesn’t support.

In this episode of the CodeCast podcast, Terry breaks down a common challenge in healthcare organizations—how to educate providers on documentation without defaulting to scolding or generic feedback that doesn’t stick.

Using real-world examples, Terry explains how to shift the conversation from criticism to clarity—helping providers understand how to document the patient story, support medical necessity, and protect reimbursement.

If your current education approach isn’t changing behavior—or your providers keep defaulting to template-style notes—this episode will give you practical, effective talking points that actually make a difference.

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Find all of Terry’s official links in one place: https://www.terryfletcher.net/links

The post Educating Physicians Without Scolding appeared first on Terry Fletcher Consulting, Inc..

If you spend your days auditing charts, you’ve seen it: diagnoses are listed, medications are “continued as prescribed,” and a plan is documented — yet something important is missing.

In this episode of CodeCast, Terry explains how small documentation improvements can make medical decision making (MDM) clearer and more defensible. Learn how generic or repetitive macro phrases can unintentionally invite payer scrutiny, and what clinicians can do to better reflect the true complexity of the encounter.

With payers increasingly using AI tools to review and downcode E/M services, clear documentation is more critical than ever. Every note should answer the essential question: Why is the patient here today?

Tune in for practical tips to strengthen your documentation and reduce audit risk.

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The post Moderate MDM — Is It Clear in the Medical Record? appeared first on Terry Fletcher Consulting, Inc..

A recurring question in Advanced Primary Care Management (APCM) is whether practices can bill every month for a patient once they’re enrolled — even if no services were provided during that month.

Terry’s stance is clear: no. APCM isn’t a subscription model or a gym membership. These are medically necessary services tied to ongoing clinical need, and billing without documented work invites unnecessary audit risk.

On today’s CodeCast, Terry breaks down why monthly billing without services is problematic, how other consultants interpret the rules, and what practices should consider to stay compliant.

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The post APCM Is Not a Gym Membership appeared first on Terry Fletcher Consulting, Inc..

Are your EMR templates helping—or hurting—your documentation? Terry dives into the difference between pre‑formatted templates and pre‑populated medical records, and why that distinction matters more than most providers realize. Pre‑populated fields can create inaccurate documentation, audit red flags, and even malpractice risk.

Terry also reviews a NAMAS article that sheds light on how this issue is showing up in real audits and what practices should watch for.

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The post Pre‑Populated EMRs Are Not Templates appeared first on Terry Fletcher Consulting, Inc..

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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The post Are You Misusing Modifier 25? appeared first on Terry Fletcher Consulting, Inc..

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..