E/M documentation for Ortho offices - Do you document appropriately for levels threes, or fours?

Event Information
Product Format
Prerecorded Event
Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR
Conference Date
Wed, May 21, 2014
60 Minutes
Product Description

Overcome your E/M Documentation Hurdles

When it comes to the correct selecting of a given E/M level of service, documentation is going to be the key issue.  We all know the saying “Not documented, not done” that is so true when it comes to supporting a given E/M level of services.  The OIG and RAC auditors are now looking ever so closely to see what documentation is being made and if there is ‘cloning’ going on.  During this session, Margie Scalley Vaught - CPC, CPC-H, CPC-I, CCS-P, PCE, MCS-P, ACS-EM, ACS-OR, will discuss what is specifically needed to support a given level in the Orthopedic Specialty.  Ortho examples will be provided and not just generic – this will be very specific to what is seen on a daily basis in the orthopedic office.

Examples will be provided regarding what a 99214, 99213 or 99203 would look like. E/M Bell Curve information will be supplied from Medicare Data for the Orthopedic, Hand and Podiatry specialties, so you will be able to see where your providers/group fall.

Session Highlights:

  • What is needed in a History and who can obtain the HPI elements
  • What is an ‘appropriate’ examination and when there might be concerns of ‘cloning’
  • Medical Decision Making – this is going to be 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
  • How often do you need to perform and/or update the complete ROS
  • Office visits and minor procedures – can you support the two or should you let the E/M go

Who Should Attend: Coders, Billers, Office Managers, Practice Manager and Orthopedic Surgeons.

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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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