E/M Coding and Auditing - Maintenance
E/M Coding and Auditing Agenda
10:00 Discuss objectives and agenda
Review the need for Internal Coding and Auditing Protocol
Utilizing 1995 vs. 1997 Documentation Guidelines
Timely documentation
EHR and its challenges
Establishing protocol for NPP documentation (including scribing)
Establishing protocol for residents and students
10:45 Review of CMS/AMA Documentation Guidelines
History: Status of 3 chronic problems
Interval history for subsequent hospital visits
Incorporation of ROS and PFSH information
Exam: Hybrid approach for use of ’95 and ’97 exam
Medical Decision Making: Versus medical necessity
3 components of MDM
Coding by time as an alternative
11:15 Addressing the gray areas of E/M auditing
12:00 30 minute lunch break
12:30 Applying internal coding and auditing policies
New patients
Consultations
Established patients
Hospital admits and daily visits
Preventive Medicine and Split Billing
1:30 Applying knowledge and presentation skills when meeting with physicians
Coder’s responsibility
Physician’s responsibility
Education, not preaching
How/when to be concerned about coding errors
2:30 Wrap up
Course Objectives
Upon completion of this course, participants should be familiar with:
Appropriate documentation of history, exam, and medical decision making
Requirements for coding by time
Application of internal policies
Best practices regarding physician interaction
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