E/M Coding, Billing & Documentation Issues for Ob-Gyn Office

Event Information
Product Format
Prerecorded Event
Jan Rasmussen, PCS, ACS-GI, ACS-OB
60 minutes
Product Description

Understand the Risk Areas for Billing EM in the Ob/Gyn Office


E/M coding might be part of your everyday routine, but that doesn’t mean you have to fall into a coding rut. The best way to boost your bottom line is reviewing and improving documentation. Every ob-gyn practice knows that audits often focus on E/M services. Every year, the Office of Inspector General (OIG) reviews common E/M mishaps.

Understand risk areas for billing EM services in the Ob/Gyn office. There can be significant lost revenue and/or risk by not billing for certain EM services or billing EM services inappropriately. This session with expert speaker Jan Rasmussen will address appropriate billing for higher level services, initial hospital care risks and billing for EM services associated with OB care. You will also get an understanding of billing a separate EM service at the time of a preventive medicine visit. You will also receive tips and handout for looking at EM levels based on the presenting problem.

Session Highlights

  • Identify the appropriate level of service that can or should be billed for confirmation of pregnancy visits
  • Does your documentation meet the minimum level for initial observation or inpatient care?  
  • Know when to bill for triage visits to the hospital
  • Documentation tips for counseling based encounters, preventive versus problem oriented counseling
  • Appropriate billing for visits during OB care.
  • Identify key elements of documentation to determine if a separate EM service is billable during a preventive medicine visit. 

Session Snapshot:

  • Medical Necessity and Cloned Documentation
  • EMR Documentation Tips
  • Level of service by presenting problem
  • 97 vs. 95 guidelines
  • Documentation and ROS Issues
    • PFSH Documentation Issues
    • Exam Documentation Issues
    • Amount and Complexity of Data Issues
    • Table of Risk and LOS Issues
  • Preventive Medicine Scenarios and Examples
    • Breast and Pelvic Exam G0101
    • Prevent Service & PPB Same Day Non Medicare Patient
    • S Code and Medicare Annual Prevent Service & PPB Same Day
    • PPB Issues
  • E/M Services during pregnancy
  • Complications during pregnancy
  • Services unrelated to pregnancy
  • Hospice care questions
  • Hospital care – Observation issues
  • Admit and Discharge Same Day Services 99234 – 99236

Who should attend?

  • Coders
  • Providers
  • Billing personnel

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About Our Speaker

Jan Rasmussen - Gastroenterology Coding Expert

Jan Rasmussen, PCS, ACS-GI, ACS-OB, is a healthcare consultant with more than 30 years of experience in physician billing, reimbursement and compliance. She is a former board member of the American Academy of Professional Coders (AAPC). As a member of the AAPC, Rasmussen previously served on the AAPC Advisory Board as the liaison to the American Medical Association (AMA).

Jan was a board member and Regional Governor for...   More Info
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