CMS (Medicare) implemented new billing rules for 2021for outpatient coding in 2021 and as of January 1, 2023 changed inpatient billing to be consistent with the outpatient rules. Specific elements of the History and Physical Exam are no longer required in your documentation. Instead, the correct code is based upon the level of Medical Decision Making or based on the time you spend caring for the patient on the day of service.

Billing incorrectly can result in Medicare penalties and loss of income. While the good news here is there are now no required elements from the history and physical exam, the rules around medical decision making are complicated and confusing. The BiilitRight App will provide the user with the correct billing code to use for the patient encounter by entering information relevant to the encounter into the App.