Live Webinar Training

Certified Medical Chart Auditor-E/M ® (CMCA-E/M)

---

The Certified Medical Chart Auditor-E/M (CMCA-E/M) program will teach experienced medical office coders how to establish an internal E/M audit program in a medical office. Updated materials include training and audit tools for hands-on practice according to 1995, 1997, and 2021 guidelines.

This training helps minimize risk areas associated with E/M coding and documentation. These claims are an ongoing audit risk and require careful human oversight.

Participants will review the structure of the medical record, coding, and documentation guidelines for 1995, 1997, and new E/M guidelines for Office or Other Outpatient Visits in 2021.

Instruction includes learning how to analyze medical records to determine whether the documentation supports CPT and medical necessity based on established coding and insurance carrier guidelines. The curriculum includes guided chart audit exercises derived from real case studies.

Course Outline:

• Medical record compliance for the medical office
• The role of a medical record auditor
• Coding and documentation for E/M services
• Review elements of medical decision making
• Using time for E/M office visits in 2021
• Revised MDM effective January 1
• Difference between medical decision making and medical necessity
• Recordkeeping, clinical documentation improvement, and physician queries
• Systematic instruction for conducting a formal chart audit
• E/M coding risk areas and compliance
• Regulatory actions and consequences for improper payments
• Comprehensive Error Rate Testing (CERT) and improper payment rates
• Guided E/M case studies with auditing tools

Course materials include a manual with coding guidelines, reference documents from the OIG and CMS, step-by-step auditing tools, and case studies.