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Clinical Documentation Improvement for Physician E/M Coding
1.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 1 Clinical Documentation Improvement for Ph Presenter Duane C. Abbey Follow us : Understand the Range and Types of E/M Codes with Particular Emphasis on Sequences of E/M Codes.
2.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 2 Presentation Faculty Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a healthcare consultant and educator with over 20 years of experience. He has worked with hospitals, clinics, physicians in various specialties, home health agencies and other health care providers. His primary work is with optimizing reimbursement under various Prospective Payment Systems. He also works extensively with various compliance issues and performs chargemaster reviews along with coding and billing audits. Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. A wide range of consulting services is provided across the country including charge master reviews, APC compliance reviews, in-service training, physician training, and coding and billing reviews. Dr. Abbey is the author of fourteen books on health care, including: •“Non-Physician Providers: Guide to Coding, Billing, and Reimbursement” •“Emergency Department: Coding, Billing and Reimbursement”, and •“Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”. Recent books include: “Compliance for Coding, Billing & Reimbursement A Systematic Approach to Developing a Comprehensive Program”, “Introduction to Healthcare Payment Systems”, “Fee Schedule Payment Systems” and “Prospective Payment Systems” from Taylor and Francis. He has just finished the fourth book in the Healthcare Payment System Series; “Cost-Based, Charge-Based and Contractual Payment Systems”.
3.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 3 Documentation for E/M Coding Review Clinical Documentation versus Payment Documentation Need Additional Documentation to Support Payment Legal Status for Coding and Supporting Documentation HIPAA TSC – Transaction Standard/Standard Code Set Standard Code Sets + Modifiers • CPT • HCPCS • ICD-9 & ICD-10 Official Guidance for Code Set Utilization CPT AMA – CPT Coding Assistant HCPCS CMS – Manual Guidance ICD-9/ICD-10 Official Coding Guidelines Special Subsets E/M CPT – CMS 1995 Guidelines – CMS 1997 Guidelines – NCCI Edits & Manual Additional Guidance for Code Sets – Depends Upon Physician Specialty Physician Specialty Societies • Example: Orthopedics – AAOS Guide Commercial Guides • Example: Dr. Z Cardiovascular Interventional Radiology
4.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 4 Documentation for E/M Coding Objectives To understand the range and types of E/M codes with particular emphasis on sequences of E/M codes. To appreciate the fundamental E/M coding requirements from CPT. To review typical types of encounters that generate given levels of E/M codes as described in the CPT Manual. To understand associated issues such as the ‘new’ vs. ‘established’ patients and the use of the “-25” modifier. To explore the process of coding by time and the documentation that is required. To understand why the Chief Complaint is important. To appreciate that both undercoding and overcoding can occur with E/M levels. To briefly review the CMS documentation guidelines from 1995 and 1997. To appreciate why Medical Decision Making is important relative to To understand the use of examination templates. To appreciate overall templates for E/M services. To understand who can perform what parts of the E/M service.
5.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 5 To see the complete presentation check the below link: http://www.audioeducator.com/medical-coding-billing/clinical-documentation- improvement-for-physician-em-coding-11-04-2014.html
6.
© 2001-2014 Abbey
& Abbey, Consultants, Inc. Slide # 5 To see the complete presentation check the below link: http://www.audioeducator.com/medical-coding-billing/clinical-documentation- improvement-for-physician-em-coding-11-04-2014.html
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