E/M Coding, Documentation, Compliance & EHR Issues

Event Information
Product Format
Prerecorded Event
Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow
90 minutes
Product Description

Train Your Providers on Handling E/M Documentation and Service Issues

Correct documentation and coding for E/M (evaluation and management) services are among the most misunderstood requirements placed on a physician. Improper documentation and/or coding for E/M services can result in major compliance violations and/or loss of income for the practice. The implementation of EHR systems which offer coding or coding recommendations has further added to the confusion and error potential.

Do you know what actions need to be taken to protect the practice for both compliance and income optimization (within the parameters as set forth by a compliant coding structure in your practice)? How do you teach E/M to your providers? What should you look for once an EHR has been implemented? How do you simplify this confounding topic for your providers to enable them to care for patients and not be overwhelmed by E/M calculations?

Join this session with certified coding instructor and compliance officer Barbara J. Cobuzzi - MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, who will take on all the above questions in detail. She will discuss the potential coding dangers related to E/M and how your providers can steer clear of them. She will also share tips and ideas for presenting E/M service issues effectively, getting E/M documentation right and discuss how to take care of EHR issues effectively.

Session Highlights

  • How to explain E/M issues and services to your providers
  • Learn how to fit all the many E/M working pieces together
  • Tips and strategies to present E/M service issues in a way that make sense to your physicians
  • Practical information and knowledge to take care of medical necessity, E/M documentation and EHR issues
  • How providers can avoid getting overwhelmed by E/M calculations
  • Guidelines for documentation and medical decision making

Session Agenda

  • Medical chart NCQA guidelines
  • Evaluation & management services
  • Office visits
  • Hospital visits (Rounds)
  • Non-procedural codes including capturing a patient’s:
    • History
    • Exam
    • And performing Medical Decision Making (MDM)
  • Medical Decision Making
  • Number of diagnosis or management options
  • Amount of data reviewed
  • Risks of morbidity and/or mortality
  • 4 possible levels or scores
    • Straight forward
    • Low Complexity
    • Moderate Complexity
    • High Complexity
  • E/M based on time
  • Documentation requirements 99251-99255
  • Consultation vs concurrent care
  • Using inpatient consultation codes
  • Consultation documentation (non medicare)
  • Discharge services

Who Should Attend

  • Physicians
  • Office managers/administrators
  • Coders
  • Billers
  • Billing managers/supervisors
  • EHR implementation personnel

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About Our Speaker

Barbara J. Cobuzzi - Healthcare Compliance Training Expert

Barbara J. Cobuzzi owns CRN Healthcare Solutions which provides value added provider consulting services. She holds a B.S. in industrial engineering from Rensselaer Polytechnic Institute and an MBA from New York University. She holds certifications from the AAPC as a CPC (certified physician coder), COC (certified hospital outpatient coder), CPC-P (certified payer coder) a CPC-I (certified coding instructor) and a CPCO (certified professional compliance officer). She also holds...   More Info
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