2018 CMS Guidelines for Physician Documentation and E&M Codes

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Upgrade Your Physician Documentation and E&M Guidelines for 2018

As physicians, coders, auditors, and billers, you must ensure that the documentation supports the encounter. How is your EMR set up for documentation? Because if all the notes look the same or all examinations are the same for every patient, you run a high audit risk. And many other documentation pitfalls will set you up for a potential scrutiny, too.

It’s time for an upgrade to ensure compliance with 2018 physician documentation requirements. This is especially important in light of the possible changes to documentation CMS is proposing for evaluation and management (E&M) codes.

In this session, coding expert Melody Irvine will discuss the CMS Proposed Policy. She will also discuss CMS’s proposed E&M code changes. She will outline the specific areas CMS is looking at for documentation and how the new focus will affect future provider documentation.

E&M codes are always on the OIG Workplan, and you want to be able to protect your institution from unnecessary audits. After attending this session, you’ll be equipped to educate your team on possible trouble areas: spots where there is or could be over-coding of encounters.  And you’ll be an expert at spotting cloned-looking documentation that could send up a red flag with the feds.

Session Highlights

In this session, Melody will discuss:

  • Possible changes CMS is proposing for E&M documentation
  • EMR concerns for documentation
  • Risks as per the OIG Workplan
  • Cloned notes and other potential risks
  • Whether your providers are actually performing the services they have documented

Session Agenda

  • Documentation risks for providers
  • Importance of documentation
  • Principles of documentation
  • CMS proposal to change E/M
  • Area of high risk due to EMR Systems
    • Copy/paste
    • Cloning
    • Templates
  • Legal aspect of documentation
  • Risk adjustment
  • EMR Concerns
  • Medical Decision Making
  • Corrections/Addendums to EMR
  • Legal ramifications of incorrect documentation

Who Should Attend

  • Physicians
  • Coders
  • Billers
  • Office Managers

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About Our Speaker

Melody S. Irvine - Medical Billing and Coding Expert

Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, AAPC Fellow, has 38 years of experience in the medical profession. She is the founder of Career Coders Online Medical Billing and Coding School with a specialty in physician auditing. Her extensive background includes director of coding, auditing, compliance, urgent care and billing for a forty-eight multi-specialty physician practice as well as a previous...   More Info
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