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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