CMS Guidelines for Physician Documentation

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

How to Identify and Eliminate Common Errors in Physician Documentation


Most physicians understand the importance of documenting services effectively; still, they end up missing important things that should be documented. Improving clinical documentation has become crucial to ensuring proper reimbursement, especially since physicians are increasingly subject to pre- and post-payment audits, as well as third-party scrutiny.

Just because a physician gets paid for services doesn’t mean he or she will continue to be paid—especially if the documentation doesn’t support the services provided. Lack of specificity can affect payment, and physicians need to understand that. But convincing them of the correlation among clinical documentation, quality of care and physician reimbursement can be challenging.

In this session, expert speaker Melody S. Irvine will guide you in analyzing documentation for the biggest issues that affect physician reimbursement. By reviewing examples of actual documentation, this webinar will help you to identify common errors in medical record documentation.

Session Highlights:

  • Why proper physician documentation is important
  • General principles of documentation
  • Legal aspects of documentation
  • Centers for Medicare & Medicaid Services (CMS) guidelines for documentation
  • Why auditing documentation is critically important
  • OIG recommendations
  • Clinical documentation improvement
  • 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

Melody will also review case studies and specific documentation tips, including:

  • Copying and pasting in electronic medical health (EMR) systems
  • The OIG’s latest on cutting and pasting
  • Risks for copying and pasting
  • Auto-populating and over-documentation
  • Templates for age and gender
  • Drop down boxes
  • New vs. established patients
  • Medical decision making (MDM)
  • Free form text

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, 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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