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Primary Care Coding Alert

You Be the Coder:

Provide Purpose for Clear Breathing Treatment Documentation

Question: I have been asking my providers for pre- and post-treatment descriptions when documenting 94640, but they don’t believe they need to provide them. Are they right? What guidelines should I use to make sure I have the right documentation? North Carolina Subscriber Answer: According to the National Correct Coding Initiative (NCCI, or CCI) Policy Manual for Medicare Services, if [...]