Clinical Documentation Improvement for Physician E/M Coding

Event Information
Product Format
Prerecorded Event
90 Minutes
Product Description

Understand the Range and Types of E/M Codes with Particular Emphasis on Sequences of E/M Codes.

This conference is one of the series of various special compliance webinars and teleconferences which concern specific coding, billing and reimbursement compliance issues. This workshop by expert speaker Duane C. Abbey, Ph.D. is a follow onto “Physician E/M Coding”. This conference is going to answer questions such as:

  • Just What Are These E/M Codes?
  • Why Is There So Much Difficulty in Selecting the Proper Levels?
  • Does the Ability of Copying and Pasting Through Electronic Documentation Impact the E/M Level Selection?
  • What Guidelines do Physician Have to Follow?
  • Can Physicians Improve Their Documentation to Better Support E/M Levels?
  • Do the CPT Guidelines Apply to All Third-Party Payers?
  • Why Did the OIG Find Such A Large Error Rate?
  • How should be Physicians Documentation for Coding by Time?
  • How Can Physicians More Easily Document Their Level of Examination?
  • Where Does the Chief Complaint Fit Into the Picture?
  • Why Is Medical Decision Making So Important?
  • Do Specialist Code Differently from Primary Care Physicians?
  • What Steps Should Physicians and Clinics Take to Improve Their Documentation?

As a participant, your take-away will be:

  • Understanding the range and types of E/M codes with particular emphasis on sequences of E/M codes.
  • Appreciating the fundamental E/M coding requirements from CPT.
  • Reviewing typical types of encounters that generate given levels of E/M codes as described in the CPT Manual.
  • Understanding associated issues such as the ‘new’ vs. ‘established’ patients and the use of the “-25” modifier.
  • Exploring the process of coding by time and the documentation that is required.
  • Understanding why the Chief Complaint is important.
  • Appreciating that both under-coding and over-coding can occur with E/M levels.
  • Briefly reviewing the CMS documentation guidelines from 1995 and 1997.
  • Appreciating why Medical Decision Making is important relative to understanding the use of examination templates.
  • Appreciating overall templates for E/M services.
  • Understanding who can perform what parts of the E/M service.

Session Highlights:

  • Introduction
    • E/M Coding
    • Documentation Guidelines
    • OIG Study
    • Copy and Paste Issues
    • Medical Necessity Issues
  • Physician E/M Coding
    • Review of E/M Codes
    • Series of E/M Levels
    • New vs. Established Patient
    • “-25” Modifier
  • E/M Coding Guidelines
    • CPT
    • Medicare 1995 Guidelines
    • Medicare 1997 Guidelines
    • Associated Coding/Documentation Guidance
  • Documentation Considerations
    • Chief Complaint
    • Use of Templates
      • History
      • Examination
    • Coding By Time – Required Documentation
    • Specialist vs. Primary Care
    • Copy and Paste
    • Medical Decision Making
    • Auditor Procedures for Reviewing E/M Levels
    • Case Studies for E/M Level Coding
  • Sources for Additional Information

Who should attend? All personnel involved with physician E/M level coding, billing, and reimbursement activities.  Compliance Officers, Compliance Analysts, Charge-master Coordinators, Internal Auditors, other compliance personnel, financial analysts and other interested administrative personnel, coding staff, health information specialists, claims transaction personnel, .patient financial management personnel.  Non-physician practitioners and physicians are encouraged to attend.

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
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