How not to undercode or overcode due to inadequate documentation

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This in-depth, 90-minute Webinar will cover the fundamentals of Evaluation and Management coding and documentation and provide an in-depth analysis of the Medical Decision Making (MDM) Process and its impact on the level of E & M service. Using specific clinical examples of Diabetes, hypertension, heart disease and glaucoma, the course will guide the participants through the different levels of MDM (Straightforward, Low complexity, Moderate complexity and High complexity), the specific documentation requirements and how they relate to the different levels of E & M (e.g., 99212, 99213, 99214 and 99215)

In this 90 Minute Webinar you will Learn:

• Fundamentals of an Evaluation and Management Encounter.
• Overview of the Medical Decision Making process and documentation Requirements
• The Marshfield Clinic Medical Decision Making Point system as adopted by Medicare Carriers and the OIG.
• Apply the concepts learned to working case studies
• Why 99.9 percent of EMR software packages will upcode your encounter.
• The importance of Medical Decision Making in 2010 due to Medicare’s dis-allowance of the E & M Consultation Codes.
• Specific documentation elements needed to quantify the level of MDM.
• How to explain the MDM process without scaring the doctors with the complexity of the Point System.
• Strategies on how to implement proper MDM documentation and coding in your clinic.
• Internet and additional Resources

Jeff will provide a thorough review of this process, using specific clinical examples, combined with detailed and accurate documentation will ensure the level of service matches the documentation reported. This presentation will include an overview of coding Evaluation and Management encounters and how to properly document the History, Exam and Medical Decision Making.

About the Presenter

Jeffrey Restuccio, CPC, CPC-H, MBA, is a certified coding and billing instructor. He has over fifteen years of coding and training experience and conducts Coding and Documentation seminars and comprehensive Coding Certification Prep Courses nationwide. He is also the author or over a dozen, online training courses for billing, coding, HIPAA, ICD-9, ICD-10 and auditing on his website: Ritecode.com.