CODING & DOCUMENTATION

You can choose an E/M code based on either total time or MDM, even when you perform multiple, separately reported services such as procedures at the same visit. However, your documentation should clearly distinguish the time you devoted to the E/M service from the time you spent providing and documenting other services. Codes for procedural services such as removing skin lesions or performing joint injections are valued to include the typical pre-, intra-, and post-service work of the procedure, so you cannot include any time you spent in activities directly associated with providing the procedure in the total time of the E/M service.

Most codes for the Medicare preventive benefits for screening Pap smear collection (Q0091) and pelvic examinations for early detection of cervical or vaginal cancer (G0101) are unchanged in 2026. However, the following codes were added to ICD-10 on Oct. 1, 2025, and are now included in the list of codes that support high-risk and annual screening, as opposed to the standard biennial screening: R87.612, “Low grade squamous intraepithelial lesion (LGSIL) on cytologic smear of cervix,” R87.810, “Cervical high risk human papillomavirus (HPV) DNA test positive,” Z84.A, “Family history of exposure to diethylstilbestrol,” Z91.B, “Personal risk factor of exposure to diethylstilbestrol. ”For a full list of codes that support screening pelvic exams, see the “Screening Pap Test” and “Screening Pelvic Exam” categories in the Medicare Preventive Services reference chart.

Regulatory agencies do not consider cost-sharing programs (where members pay fees and agree to share each other's eligible medical costs as outlined in membership contracts) to be insurance. So if the patient does not have any other health insurance or health program benefits (e.g., Medicare, Medicaid, or private medical insurance), then the patient is uninsured for billing purposes. You may collect payment at the time of service per your practice's policies. The patient will likely require a claim form or itemized statement to submit to the cost-share program for reimbursement. You should also provide these patients a good-faith estimate of the costs before performing services for them, as required under the No Surprises Act.

ICD-10 instructs clinicians to report a code for each condition to the highest degree of certainty for that visit, so report what you know at the time of the encounter.For instance, if your working diagnosis is a sprain with possible scaphoid fracture, report a code for the sprain (e.g., S63.522A, “Sprain of radiocarpal joint of left wrist, initial encounter”) and any other conditions you address at the encounter. You may report additional codes to provide the payer with information on the external causes of the injury (e.g., W00.1XXA, “Fall from stairs and steps due to ice and snow, initial encounter,” or Y92.014, “Private driveway to single-family [private] house as the place of occurrence of the external cause”). But those additional codes are not mandatory.