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Coding and Documenting Evaluation and Management Services: A Physician's Perspective - Webinar (Recorded)

  • Webinar

  • 60 Minutes
  • September 2018
  • Compliance Online
  • ID: 4899766
Why Should You Attend:

Coders and auditors are valuable players in a healthcare organization’s compliance and revenue cycle operations. Additionally, the OIG has recommended that a physician or other clinically trained person also be involved in audits: “The individuals from the physician practice involved in these self-audits would ideally include the person in charge of billing (if the practice has such a person) and a medically trained person (e.g., registered nurse or preferably a physician (physicians can rotate in this position).”

Understanding a physician’s perspective on Evaluation and Management (E/M) services is essential to proper coding, billing and compliance operations.

Attend the webinar to learn the physician’s perspective on how documentation and medical necessity play into appropriate coding and compliance for these E/M services. Learn how a physician thinks about the words, phrases and concepts in the 1995 and 1997 E/M documentation guidelines.

For example, the 1995 table of risk uses the phrase “Parenteral controlled substances” for high risk. What does this mean? Could as coder auditor identify which prescribed medications or physician orders signify a “parenteral controlled substance” is in play when they are determining risk? Or, when might a presenting chief compliant of “headache” actually turn out to be high risk?

It is true that physicians need to document, but it is also true that coders and auditors need to understand what certain words, phrases, orders, and clinical plans mean when a physician uses and documents them.

Areas Covered in the Webinar:

The elements of the 1995 and 1997 E/M documentation guidelines with a focus on the physician’s perspective of the:

History components
Chief complaint
History of present illness
Review of systems
Past/family/social history
Physical exam
How would a physician view “Problem Focused,” “Expanded Problem Focused” “Detailed” and “Comprehensive” along with the nuances and ambiguities that often arise in documentation of the exam
Medical decision making
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality

Speakers

C.J. Wolf, MD, M.Ed. has been involved in healthcare for over 20 years beginning with his years in medical school. Shortly after graduating Dr. Wolf made a career change to healthcare administration, reimbursement and compliance. He has worked in various coding, reimbursement or Chief Compliance Officer roles for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System and Merit Medical Systems. He currently is Sr. Compliance Executive at Healthicity.

Dr. Wolf has a passion for teaching and education. He has developed and taught curricula for adult employees seeking national coding certifications, trade workshops and seminars, and has served as adjunct faculty for Salt Lake Community College and currently is Faculty at Brigham Young University-Idaho and adjunct faculty at the University of Illinois at Chicago College of Medicine.

In addition to his medical degree from the University of Illinois at Chicago College of Medicine, Dr. Wolf holds a master of education (M.Ed.) from the University of Texas at Brownsville. He completed his B.S., magna cum laude, from Brigham Young University, Provo, UT.