This document outlines a presentation on clinical documentation improvement for physician E/M coding. The presentation will cover understanding the range of E/M codes with an emphasis on code sequences, E/M coding requirements from CPT, typical encounters for different code levels, issues like new vs. established patients, coding by time requirements, the importance of the chief complaint, undercoding and overcoding risks, CMS documentation guidelines, the role of medical decision making, examination templates, overall templates for E/M services, and who can perform different parts of the E/M service. The presenter, Duane C. Abbey, is an experienced healthcare consultant and educator who will review these topics to help optimize reimbursement under prospective payment systems.

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