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Poor documentation is a ticking time bomb. Most practices are deficient in their level of service documentation. This exposes the practice to a tremendous liability.
Course Overview
- Participants will gain a thorough understanding of the E/M code selection process.
- Receive a comprehensive explanation of documentation guidelines and the guiding
principles of accurate, adequate and clinically useful information.
- Learn how to implement a consistent, ongoing internal self-audit program that will help staff proactively identify and correct potential problems.
Can your office withstand a RAC audit? In our experience, most practices cannot.
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What Every Coder Must Know
E/M lays the groundwork for the reimbursement process. Are you confident that the E/M codes that your physician is giving you are correct? Medicare and other third party payers review physician billing profiles. Get the tools and the knowledge to evaluate whether chart documentation holds up. Participants will gain excellent comprehension in the following areas:
- Relate accurate code selection to proper reimbursement
- Test your diagramming skills with sample chart notes
- Step-by-step explanation of documentation guidelines
- The down side of using EMR templates for EM code selection
- Select proper E/M code for location and type of service provided to the patient
- Explanation of proper add-on code usage
- Look at appropriate codes for work performed by ancillary providers
- Instruction of diagnosis codes indicating level of necessity
- E/M coding grids to aid in accurate level of service selection
- What is necessary in the medical record
- E/M audit triggers
- When to use E/M services based on 4 types of examination
- Documentation requirements needed to bill based on time
- Correct use of Level II CPT modifiers
- How documentation is used to record the complexity of medical decision making
- The role of history and exam in medical decision-making
- Review examples of chart notes to identify potential problem areas
- Proper use of modifiers 25 and 57
- The dangers of using EMR standard templates for each visit
- Understanding the difference between a consultation and a referral
- How will RACs change the face of E/M coding
Who Should Attend
This is an intermediate level course, appropriate for physicians, physician coders and billing staff seeking a better understanding of the backbone of the medical claim.
Prerequisites
At least six months of coding experience is required for maximum course benefit.
What to Bring
All students must bring current editions of CPT & ICD-9-CM Vols. I and II to this class. These references may be purchased at www.pmiMD.com or by calling 800-259-5562.
Class Materials
A course manual will be provided. Participants will also receive bonus E/M Coding Grids, developed by PMI, for accurate selection of E/M level of service codes.
CEUs
A certificate of attendance will be provided. PMI-certified professionals (CMC, CMIS, CMOM) receive up to 6 CEUs for attendance. CEU credit is based on total number of instructional hours. Review pre-approval and credit guidelines prior to enrollment if you are seeking CEUs from other organizations.
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