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..

OpenAI’s launch of ChatGPT Health is reigniting a familiar debate about patient‑facing AI — how much it can empower people to access medical information, and how much it might amplify misinformation, anxiety, or privacy risks.

ChatGPT Health allows users to securely enter personal health information and use ChatGPT’s AI to better understand and manage their health concerns. Physicians note, however, that its impact on care will depend heavily on guardrails around accuracy, transparency, and how patients use the tool between visits.

In this episode, Terry breaks down the pros and cons of AI in healthcare and highlights what providers should be cautious about as these tools become more common.

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The post The Pros and Cons of ChatGPT for Healthcare appeared first on Terry Fletcher Consulting, Inc..

Time-based coding can be a powerful, defensible approach for E/M services—when it’s documented the right way. But vague or incomplete time notes can open the door to denials, audits, and compliance problems.

In this episode, Terry breaks down the exact language, documentation elements, and inclusions you need to make time-based E/M coding hold up. She also covers Care Management Services, their time requirements, and how to avoid overlapping time pitfalls. Tune in for a clear, practical walkthrough.

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Telehealth isn’t going anywhere, but many practices still don’t have a solid audit plan in place. With Medicare’s proposed rules now finalized for 2026—and the added uncertainty of another potential government shutdown—it’s easy to see why compliance teams are feeling the pressure.

In this episode, Terry breaks down five practical tips to help you strengthen or update your telehealth audit plan, especially if you’re providing office visits via telehealth through January 30, 2026. We also highlight insights from Sonal Patel and her excellent NAMAS article on this very topic.

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Terry kicks off 2026 by clearing up a major misunderstanding in the provider and manufacturer community. Some believed that CMS’s last‑minute withdrawal of the LCD for skin substitute products would delay or stop the 2026 reimbursement changes.

That’s not the case. The LCD withdrawal has no impact on the Final Rule, and the new 2026 reimbursement methodology for skin substitutes will move forward exactly as finalized, using an incident‑to payment structure.

In this episode, Terry breaks down the difference between the policy halt and the reimbursement rules, and explains what providers need to know about the updated approach to skin substitutes and skin graft products and services.

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The post Skin Substitutes and Grafts LCD vs Reimbursement 2026 appeared first on Terry Fletcher Consulting, Inc..

Terry closes out the year with a deep dive into Medicare’s newly permanent “Virtual Supervision” rule taking effect in 2026, along with a refresher on the current requirements for reporting services under a physician’s NPI versus an NPP’s NPI.

She urges listeners to approach this shift carefully, outlining the risks tied to non‑compliance, malpractice exposure, and whether patient‑safety concerns outweigh any potential financial upside. Tune in to get the context you need before jumping into this virtual model.

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The post Is Virtual Supervision a Good Idea for 2026? appeared first on Terry Fletcher Consulting, Inc..