2017 CMS Guidelines for Physician Documentation

Event Information
Product Format
Prerecorded Event
Presenter(s)
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, AAPC FELLOW
Length
60 minutes
Product Description

Analyze the Major Physician Documentation Issues That Affect Reimbursement


Most physicians end up missing crucial elements while documenting services, even though they understand the importance of documenting them effectively. In order to ensure proper reimbursement, improving clinical documentation has become essential, especially since physicians are increasingly subjected to pre- and post-payment audits, as well as third-party scrutiny.

Even though you have been getting paid for your services, it does not mean that the payment will continue, unless your documentation supports the services that you provided. You need to understand that your payment could be affected by lack of specificity. However, getting to know about the correlation between clinical documentation, quality of care and physician reimbursement can be a challenge.

In this session, expert speaker Melody S. Irvine will assist you in analyzing documentation for the biggest issues affecting physician reimbursement. Melody will assist you in identifying common errors in medical record documentation by reviewing examples of actual documentation.

Session Highlights:

  • Importance of proper physician documentation
  • General principles of documentation
  • Documentation – legal aspects
  • Documentation guidelines from Centers for Medicare & Medicaid Services (CMS)
  • Importance of auditing documentation
  • OIG recommendations
  • Improvement in clinical documentation
  • Common documentation errors identified by the Recovery Audit Contractors (RAC) and Comprehensive Error Rate Testing (CERT) programs
  • Common evaluation and management (E&M) services identified by CERT
  • How to identify incomplete documentation
  • Medicare’s policy on medical necessity
  • Insights on E&M medical necessity
  • Legal ramifications of incorrect documentation

 Session Agenda:

  • Risk adjustment
  • Problems with incomplete documentation
  • Medical necessity: Reasonable and necessary services
  • E/M medical necessity
  • OIG and Joint Commission take on copy and paste
  • Templates for ages and gender
  • New and established patient documentation
  • Examples of MDM and diagnosis

Who should attend?

  • Auditors
  • Office managers
  • Physicians
  • Coders

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About Our Speaker

Melody S. Irvine - Medical Billing and Coding Expert


Melody S. Irvine has over 30 years of experience in the medical profession. She is the founder of Career Coders Online Medical Billing and Coding School. She specializes in physician auditing, education, curriculum development and is an approved Instructor with AAPC. Her extensive background includes Director of Coding, Auditing, Compliance, and Urgent Care for a forty-eight multi-specialty physician practice and contract auditor for State of...   More Info
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