Overview
Lessons Learned From Auditing E & M- Observations & Solutions
Speaker: Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM
CE: 1.0 – Data Structure, Content and Information Governance
Session Description:
January 2021 heralded the introduction of new Evaluation and Management Guidelines in the Outpatient Setting. This was the first major change in these guidelines since the rollout of the initial E & M guidelines and the introduction of the 1997 E & M guidelines. These new guidelines now recognize the critical nature and importance in the documentation of Medical Decision Making, the crux and fundamentals of medicine in contrast to the 1995 guidelines where providers were relegated to counting bullets in the documentation of History & Physical Exam. Medical Decision Making is now the key component of E & M assignment with a medically appropriate History & Physical. Time is an alternate means of E & M assignment in place of Medical Decision Making. This presentation will provide observational learnings and personal experiences from a coding consultant’s point of view in conducting over 2,000 provider reviews of office visits, the good, bad, and ugly. Opportunities abound for clinical documentation improvement throughout most patient encounters. Attendees will learn specific deficiencies in documentation to be aware of and home in on when reviewing documentation for E & M assignment. Strategies will be shared to identify opportunities for documentation improvement and how best to address with physicians using a clinical medicine approach to education and training versus a “coding approach” that is often not grasped by physicians. Ample time will be allowed for attendee questions and answers. Real case studies will be used as part of the discussion within the presentation to showcase and emphasize complete and accurate physician documentation versus insufficient documentation.
Date Published
April 21, 2022
Pricing
- AHIMA/FHIMA Member – $20.00
- Non-Member – $30.00
CE
# of CEs: 1.0 – Data Structure, Content and Information Governance
AHIMA
This educational offering has been approved for continuing education credit for use in fulfilling the continued education requirements of the American Health Information Management Association (AHIMA).
AAPC
CEUs are accepted from programs sponsored by AHIMA national offices and the state or regional AHIMA branches. One hour of instruction is worth one CEU. A certificate of attendance or completion is necessary to show participation.
Instructions
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FAQs
- Access instructions for the course will be emailed to you within 2 business days following receipt of payment.
- You will have 60 days to access the course. If your course has expired, and you need an extension, please contact us.
- You must click on the button labeled “Mark Complete” at the bottom of each course page before the CE will appear on the My Certificates page.
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Course Includes
- 4 Lessons
- Course Certificate
