E/M Documentation in Orthopedics: Learn to Do It Correctly With Specific Examples

Event Information
Product Format
Prerecorded Event
Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR
60 minutes
Product Description

Take Proactive Stance in Overcoming E/M Documentation Hurdles


Due to changes in reimbursement and increased scrutiny by third-party payers, documentation has become even more of a strategic imperative than ever before. When it comes to E/M coding, the saying “if it hasn’t been documented, it didn’t happen”, couldn’t be more true. Documentation is critical especially in determining an E/M level of service. OIG and RAC auditors are now looking ever so closely to see what documentation is being made and if there is ‘cloning’ going on.

Join expert speaker Margie Scalley Vaught in this session to discuss what is specifically needed to support a given level in the orthopedic specialty. She will shed light on specific orthopedic examples, and what is seen on a daily basis in the orthopedic office. Learn from examples regarding what a 99214, 99213 or 99203 would look like.

Additionally, Margie will provide insights on the EM Bell Curve information from Medicare data for the orthopedic, hand and podiatry specialties—it will help you to see where your providers/group fall.

Session Highlights:

  • Difference between New and Established Patients.
  • Key components of History
    • History of Present Illness (HPI)
    • What is needed in a History and who can obtain the HPI elements?
    • Importance of HPI
    • Review of systems (ROS)—how often do you need to perform and/or update the complete ROS?
    • When do you need PFSH?
  • What is an ‘appropriate’ examination and when there might be concerns of ‘cloning’?
  • Auditing Tips
  • Insights on examination elements
  • Signs-Tests-Maneuvers
  • Review Rx Drug Management
  • Insights on 1995-1997 Guidelines
  • Understanding Medical Decision Making (MDM) – the ‘meat and potatoes’ of your full documentation – without the medical necessity issues being documented the level may be down coded by the payer/auditor/carrier
  • Cloning—what you need to know?
  • Office visits and minor procedures – can you support the two or should you let the EM go?
  • Review of common EM issues
  • New CMS Study findings
  • EM Issues

Who should attend

Coders, Billers, Office Managers, Practice Manager, Orthopedic Surgeons

Order Below or Call 1-844-384-4744 Today

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About Our Speaker

Margie Scalley Vaught - Wound Care Coding Expert

With over 30+ years’ experience in the Healthcare arena, in positions from nurse’s aide to ward clerk and medical transcriptionist to office manager, Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR, understands how offices are structured.  Margie spent twenty years in the field of Orthopedics.  She obtained Certified Professional Coder (CPC) designation in 1995 from the American Academy of Professional Coders (AAPC), where she served...   More Info
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