CodeCast | Medical Billing and Coding Insights

Terry tackles a growing compliance issue in telehealth: where the patient is located at the time of the visit. While physicians generally must be licensed or otherwise authorized to practice in the state where the patient is physically located, evolving payer policies and Medicare rules have added new layers of complexity. From commercial insurance requirements to CMS guidance on services provided outside the United States, Terry explains what providers need to know to remain compliant and avoid costly reimbursement pitfalls. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Telehealth: Where the Patient is or Where the Provider is? appeared first on Terry Fletcher Consulting, Inc..

Every CMS-1500 claim includes a set of certifications, attestations, and legal statements printed on the reverse side of the form. While these statements may seem like standard administrative language that has been around for decades, they carry significant legal and compliance implications. In this episode, Terry breaks down what these certifications actually mean and why every claim submitted is a legal representation that the services billed were properly documented, medically necessary, accurately coded, and provided in compliance with applicable regulations. She also explains why understanding these attestations is essential to maintaining a strong revenue cycle management (RCM) workflow, reducing compliance risk, and helping organizations avoid costly payer audits. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post CMS-1500 Form Compliance appeared first on Terry Fletcher Consulting, Inc..

A growing concern among auditors, coders, and compliance professionals is the increasing reliance on template driven documentation. While electronic health records have improved efficiency, copied, carried-forward, and pre-populated information can create significant compliance risks when it does not accurately reflect the patient’s current encounter. Auditors frequently identify contradictory statements, outdated histories, normal findings that conflict with the assessment and plan, and documentation that appears disconnected from the services actually provided. Simply completing documentation fields does not create credible documentation. On this episode of the CodeCast Podcast, Terry discusses why E/M documentation is not a checklist, the compliance risks associated with template generated notes, and practical strategies to ensure your documentation accurately tells the patient’s story and supports the care delivered. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post E/M Documentation Is Not a Checklist: Tell the Patient’s Story appeared first on Terry Fletcher Consulting, Inc..

Auditors, coders, billers, and even physicians often find themselves searching through pages of documentation trying to answer one basic question: what was actually evaluated, managed, and medically necessary during a single patient visit? With note bloat from copied and pasted EMR documentation and pulled-forward notes, it has become increasingly difficult to determine what actually happened “today.” In this episode of the CodeCast Podcast, Terry breaks down this compliance challenge and explains how providers can better manage documentation to ensure accuracy, clarity, and compliance. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Note Bloat Is an Auditor’s Nightmare appeared first on Terry Fletcher Consulting, Inc..

HHS recently released updated Notices of Privacy Practices (NPPs), introducing changes that go far beyond standard template revisions. The update includes new requirements for health care providers, health plans, and Part 2 patient notices related to sensitive protected health information. While many in health care associate “NPP” with Non-Physician Practitioner, in this case it refers to patient privacy notice requirements involving highly sensitive health information, including substance use disorders (SUD), reproductive health information, and mental health records. These updated privacy notice requirements became effective February 16, 2026, and covered entities must comply by July 1, 2026. In this episode, Terry breaks down what has changed, what practices need to update immediately, and how to ensure your organization remains compliant with both HIPAA and the new federal privacy requirements surrounding sensitive PHI. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Notice of Privacy Practices 2026 appeared first on Terry Fletcher Consulting, Inc..

While Centers for Medicare & Medicaid Services does not explicitly define a strict “12-month rule,” its guidance does require that the physician’s involvement reflect ongoing, active participation in the patient’s course of treatment. That said, legal and compliance experts consistently caution that if a physician has not personally seen a patient within 12–24 months, billing subsequent non-physician practitioner (NPP) visits as “incident to” may present elevated audit risk. Terry breaks down the lack of clear regulatory thresholds and outlines practical steps to help protect your practice if an audit inquiry occurs. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Incident to Physician Participation Rules appeared first on Terry Fletcher Consulting, Inc..

Modifier 59 (Distinct Procedural Service) continues to face intense scrutiny in 2026 due to widespread misuse, triggering audits, denials, appeals, and payer recoupments tied to medical necessity concerns. With enforcement on the rise, it’s more important than ever for coders to understand when—and when not—to apply this modifier correctly. On today’s episode of the CodeCast Podcast, Terry Fletcher breaks down proper Modifier 59 usage, common pitfalls leading to audits, and key documentation requirements to support compliant coding. She also covers post-operative pain injections, including when they can be reported and which providers are eligible to bill for them. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Modifier 59 Audits Denials and Post-Op Pain Injections appeared first on Terry Fletcher Consulting, Inc..

In medical coding and compliance, attention is often focused on overcoding due to its association with fraud, waste, and abuse. However, undercoding is an equally important—and frequently misunderstood—issue. While it may seem like a safer way to avoid scrutiny, undercoding is still a coding error, a compliance concern, and a reportable variance under both CMS and OIG guidelines. Recent TPE audits are increasingly targeting undercoding, as it signals a failure to accurately report services and can negatively impact compliance, data integrity, and reimbursement. In this episode, Terry breaks down why undercoding is now on the radar and why providers need to address it immediately. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Undercoding Is Now a Compliance Risk Providers Can’t Ignore 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. Subscribe and Listen 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..

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. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post APCM Is Not a Gym Membership 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. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post Are You Misusing Modifier 25? 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. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post The Compliance Gap in Ambient AI Scribing and Informed Consent appeared first on Terry Fletcher Consulting, Inc..

OpenAI’s launch of ChatGPT Health is reigniting a familiar debate about patient‑facing AI — how much it can empower people to access medical information, and how much it might amplify misinformation, anxiety, or privacy risks. ChatGPT Health allows users to securely enter personal health information and use ChatGPT’s AI to better understand and manage their health concerns. Physicians note, however, that its impact on care will depend heavily on guardrails around accuracy, transparency, and how patients use the tool between visits. In this episode, Terry breaks down the pros and cons of AI in healthcare and highlights what providers should be cautious about as these tools become more common. Subscribe and Listen Find all of Terry’s official links in one place: https://www.terryfletcher.net/links The post The Pros and Cons of ChatGPT for Healthcare appeared first on Terry Fletcher Consulting, Inc..