When auditing a medical record, a common mistake is viewing it solely from a coding perspective rather than an auditing perspective. True auditing requires examining not just the encounter itself, but also what occurred before, after, and around it.
Focusing only on coding can result in missed compliance elements and insufficient support for what was—or will be—billed, potentially triggering a formal payer audit.
Terry breaks this all down in today’s episode of the CodeCast podcast.

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The September 2025 issue of CPT® Assistant raised important questions about how to appropriately level an evaluation and management (E/M) encounter when the presenting problem is an acute, uncomplicated illness or injury. A growing number of providers have been assigning Level 4 codes simply because an antibiotic was prescribed.
However, this approach may not be accurate when considering the full scope of the encounter and its required documentation elements.
Terry examines this trend and explains why many payers have responded by implementing automatic down-coding policies to address potential overcoding.
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Medical billing and coding encompasses a wide range of responsibilities—from patient registration and claim reimbursement to final payment delivery to the provider. Navigating this process requires close collaboration among billers, coders, insurance companies, patients, and various healthcare professionals.
Although often grouped together as a single discipline, billing and coding are distinct roles that work in tandem to support the healthcare revenue cycle. If you’re considering a career in medical billing and coding, it’s essential to understand that these are separate professions, each demanding unique skills and personality traits. Terry breaks down the individual roles and how they work together to keep the system running smoothly.
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As more practices begin offering screening services, questions around billing for Medicare-specific G codes are becoming more common. In this episode, Terry breaks down when it’s appropriate to bill for preventive services, which providers are eligible, and what requirements must be met.
To bill G codes, providers must be enrolled as Medicare suppliers and follow specific program rules. Eligibility varies by service type—some require enrollment in specialized programs like the Medicare Diabetes Prevention Program (MDPP). For instance, pharmacists can only bill for certain services if certified as DSMT practitioners.
Tune in for real-world examples and expert guidance on navigating preventive service billing.
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CMS has updated its stance on Medicare payments during the federal shutdown, confirming that only certain claims will be held—reversing earlier guidance that hinted at a wider pause. But what does this mean for Telehealth and other temporary policies that expired on October 1?
Terry breaks down the latest developments, what’s at risk, and what steps to take next on today’s CodeCast Podcast.
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In this episode, Terry tackles a common pitfall in coding and CDI workflows: skipping straight to the Assessment and Plan (A/P) section of an E/M note to determine service level. Are you overlooking key documentation that could support medical decision-making, risk, or time?
She also calls out a frequent habit among surgery coders—coding from the report header instead of the full operative detail. What assumptions are being made based on titles alone? What critical elements might be missed or misinterpreted?
Terry breaks down why accuracy isn’t enough. Coders must be diligent, thorough, and intentional in their medical record reviews and extrapolation processes. Lazy shortcuts can lead to compliance issues, missed revenue, and flawed data.
Tune in for practical insights on how to elevate your coding practices and avoid costly oversights.
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Terry explores the critical role coders and auditors play in holding providers accountable. From reviewing clinical documentation and medical record notes to verifying patient eligibility, addressing cases where minors receive treatment without a parent present, and identifying excessive repeat visits lacking medical necessity, this episode highlights the detailed oversight that ensures provider compliance and quality care.
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In this episode, Terry breaks down the upcoming Prior Authorization pilot programs launching for Medicare Part B Professional Services on January 1, 2026, and for Ambulatory Surgical Centers starting December 15, 2025. She outlines which medical services will be impacted and what providers need to know as these changes roll out.
Terry also shares the latest updates on Telehealth and explains how to access the educational materials from the September 18th webinar if you missed it.
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In this episode of the CodeCast Podcast, Terry addresses a common misconception among medical providers: the belief that simply listing a patient’s medications or repeatedly noting “continue meds” is enough to support a moderate-level evaluation and management visit, such as CPT codes 99214 or 99204. In reality, this documentation alone does not meet the criteria.=
Payers—including MACs, commercial insurers, and Medicaid programs—are increasingly updating their policies to clarify that providers must demonstrate the cognitive effort involved in assessing the risks tied to prescription drug management. Reviewing a medication list without further analysis or context is not sufficient. Instead, documentation should reflect the clinical reasoning, counseling, and risk evaluation discussed with the patient, including potential outcomes related to medication adherence or non-adherence.
Terry breaks down what this means for coding accuracy and compliance, offering insights into how providers can better capture the complexity of prescription drug management in their documentation.
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In this episode of the CodeCast Podcast, Terry addresses a common misconception among medical providers: the belief that simply listing a patient’s medications or repeatedly noting “continue meds” is enough to support a moderate-level evaluation and management visit, such as CPT codes 99214 or 99204. In reality, this documentation alone does not meet the criteria.=
Payers—including MACs, commercial insurers, and Medicaid programs—are increasingly updating their policies to clarify that providers must demonstrate the cognitive effort involved in assessing the risks tied to prescription drug management. Reviewing a medication list without further analysis or context is not sufficient. Instead, documentation should reflect the clinical reasoning, counseling, and risk evaluation discussed with the patient, including potential outcomes related to medication adherence or non-adherence.
Terry breaks down what this means for coding accuracy and compliance, offering insights into how providers can better capture the complexity of prescription drug management in their documentation.
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A split or shared visit is an evaluation and management (E/M) service performed jointly by a physician and a non-physician practitioner (NPP) from the same group in a facility setting. Under applicable laws and regulations, either the physician or the NPP may bill for the service—provided they deliver it independently. Reimbursement goes to the practitioner who performs the substantive portion of the visit.
However, many practices mistakenly confuse shared visits with “incident to” services, which are fundamentally different. In this episode of the CodeCast podcast, Terry breaks down the distinction and clears up the confusion.
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In this week’s episode of the CodeCast Podcast, Terry Fletcher previews potential Telehealth updates and changes set to take effect on October 1. She also discusses how major surgery can be considered a risk factor in Evaluation and Management coding, and explains the importance of properly sequencing ICD-10-CM codes to ensure reimbursement success.
Listeners are encouraged to check out the latest Telehealth webinar, available now at www.terryfletcher.net.
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In this episode of CodeCast, Terry takes a closer look at the growing issue of undercoding in healthcare. Often misunderstood or overlooked, undercoding involves reporting fewer services than were actually provided, assigning a lower-level code than warranted, or inaccurately documenting patient encounters.
While some may view it as a conservative approach to avoid audits or reduce patient costs, under-coding can lead to serious consequences—including reduced reimbursement, skewed provider data, and potential compliance violations.
Terry breaks down how this practice is being viewed in today’s regulatory landscape and what it means for coders, providers, and healthcare organizations.
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In this episode of CodeCast, Terry dives into the complexities of billing bilateral procedures and the growing tension between Medicare guidelines and commercial payer policies. Modifier 50 is used to report procedures performed on both sides of the body during the same operative session. When billed correctly, the procedure should appear on a single claim line with the CPT or HCPCS code, modifier 50, and one unit of service. Depending on the procedure’s bilateral indicator, Medicare may apply a 150% payment adjustment.
However, commercial payers are increasingly rejecting this standard. Many are now reimbursing only one line item, effectively ignoring the bilateral nature of the procedure. This shift poses serious risks to patient care. Providers may be forced to schedule a second surgery, exposing patients to additional anesthesia and delaying medically necessary treatment.
Terry breaks down the implications of these policy changes and offers strategies for providers to advocate for proper reimbursement. Tune in to learn how to protect your patients and your practice from the fallout of this troubling trend.

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