Coding and Documenting Evaluation and Management Services: A Physician's Perspective

This webinar will give the physician’s perspective on how documentation and medical necessity play into appropriate coding and compliance for these E/M services. How coders and auditors need to understand what certain words, phrases, orders, and clinical plans mean when a physician uses and documents them.

Why Should You Attend:

Coders and auditors are valuable players in a healthcare organization’s compliance and revenue cycle operations. Additionally, the OIG has recommended that a physician or other clinically trained person also be involved in audits: “The individuals from the physician practice involved in these self-audits would ideally include the person in charge of billing (if the practice has such a person) and a medically trained person (e.g., registered nurse or preferably a physician (physicians can rotate in this position).”

Understanding a physician’s perspective on Evaluation and Management (E/M) services is essential to proper coding, billing and compliance operations.

Attend the webinar to learn the physician’s perspective on how documentation and medical necessity play into appropriate coding and compliance for these E/M services. Learn how a physician thinks about the words, phrases and concepts in the 1995 and 1997 E/M documentation guidelines.

For example, the 1995 table of risk uses the phrase “Parenteral controlled substances” for high risk. What does this mean? Could as coder auditor identify which prescribed medications or physician orders signify a “parenteral controlled substance” is in play when they are determining risk? Or, when might a presenting chief compliant of “headache” actually turn out to be high risk?

It is true that physicians need to document, but it is also true that coders and auditors need to understand what certain words, phrases, orders, and clinical plans mean when a physician uses and documents them.

Areas Covered in the Webinar:

The elements of the 2021 Office and Outpatient E/M documentation guidelines with a focus on the physician’s perspective of the:

Time

• Face to face time with the patient
• Non face to face time to include reviewing records and documenting the encounter

Medical decision making

• Number of problems addressed
• Amount and/or complexity of data to be reviewed and analyzed
• Risk of complications and/or morbidity or mortality

Who Will Benefit:

• Coders
• Auditors
• Compliance Personnel
• Physicians
• Nurse Practitioners
• Physicians Assistants
• Coding and Reimbursement Consultants