Many EMRs now embed ICD‑10 and CPT codes directly into the medical record. But is that advisable? The safest approach is still to let the documentation stand on its own. The content of the record should support the coding choices, and coders and auditors should base their work on the medical facts as documented. Codes can—and should—be applied only after the documentation is complete.

On today’s CodeCast episode, Terry explains that when providers insert billing codes into the note, the intention may be good, but the risk of contradictions or inaccuracies can outweigh any perceived benefit.

Should medical record documentation stand alone, without templated teaching language that was never meant to be included? Should codes appear in the record simply to give the impression of accuracy, rather than allowing the documentation to speak for itself?

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The post Who’s Doing the Coding — Providers or Coders? appeared first on Terry Fletcher Consulting, Inc..

When performing audits, the same macro statements keep appearing in progress notes: ambient AI scribing was used to create the documentation, and the note may contain errors. The pattern mirrors what happened when early talk‑to‑text tools rolled out. From a patient’s perspective—especially someone with little or no understanding of ambient AI scribing—this raises real questions about whether they truly understood what was used during their visit and what they were consenting to.

Terry breaks down this issue this week, drawing on an excellent article by Stephanie Allard, RHIT, to explore informed‑consent workflows, compliance expectations, and liability concerns surrounding Ambient AI Scribing.

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The post The Compliance Gap in Ambient AI Scribing and Informed Consent appeared first on Terry Fletcher Consulting, Inc..

The 2026 updates introduced new and revised PCI CPT codes, and even experienced coders are feeling the impact. With fresh code options and shifting applications, accurately capturing Coronary Intervention services—and protecting revenue—has become more challenging.

In this episode, Terry breaks down what’s changed, how to navigate the nuances, and what you need to know about bundling rules to stay compliant and confident.

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The post Cardiology PCI Coding Made Clear appeared first on Terry Fletcher Consulting, Inc..