Coding & Documentation

If your EHR's cut-and-paste feature is enabled, you should not use it. The Centers for Medicare & Medicaid Services (CMS) recommends disabling cut and paste,¹ which removes text from an existing note and places it into a new note.

The copy-and-paste feature is a better option. It does not disturb the integrity of an existing note but still allows you to carry certain information (e.g., past medical and social history) to a new note without retyping it. Make sure you review and, if necessary, update any information that you copy and paste.

Artificial intelligence programs may now allow you to carry forward or summarize information from prior documentation with a voice command or a short prompt. The same best practices apply: Make sure the previous note is not altered and the new note is updated as needed. The physician reporting the service in the new note is responsible for reviewing the documentation for accuracy and including only what is applicable to the current service.

Codes 98970-98972 are for patient-initiated e-visits provided through a secure online portal by qualified non-physician health care professionals — those whose training, licensure, and state-defined scope of practice does not include providing E/M services. These are not clinical staff working under a physician's supervision (e.g., nurses or medical assistants, whose E/M services would be reported with 99211). Rather, these are professionals such as physical therapists, occupational therapists, and speech-language pathologists whose scope includes non-E/M assessment and management services, usually based on a physician's order and referral. Only physicians and non-physician clinicians (e.g., advanced practice nurse practitioners and physician assistants) can independently provide and report E/M services, including codes 99421-99423 for online digital E/M services.

Medicare Part B covers tetanus and diphtheria toxoids (Td, 90714) or tetanus, diphtheria toxoids, and acellular pertussis vaccine (Tdap, 90715) when administered due to a current injury. The diagnosis code linked to the vaccine and administration code (90471) should indicate the injury that prompted immunization (e.g., S91.331A, “Puncture wound without foreign body, right foot, initial encounter”), not the type of encounter (e.g., Z23, “Encounter for immunization”). A payer may also require modifier AT (active treatment) on the vaccine and administration codes, although this informational modifier doesn't usually affect payment. When you report an E/M service on the same date, append modifier 25 to indicate that the service was beyond the typical work of immunization administration (and/or any wound repair procedure you provided).