Auditing Records with New 2022 Evaluation and Management Rules

Stephanie Thomas, CPC, CANPC, COSC

Stephanie Thomas, CPC, CANPC, COSC

Stephanie has worked in the medical, billing and coding industry for nearly 20 years. It is truly her passion. Stephanie works closely with small and large private practices to audit and collaboratively improve their revenue stream. She prides herself in her dedication to her clients and has built a team of incredible billers and coders to...
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60 Mins
Stephanie Thomas, CPC, CANPC, COSC

Develop and Implement a Successful E/M Audit plan

Evaluation and Management coding and documentation are among the top auditing items in healthcare. The reason being that there is a lot of room for interpretation. Providers know what they are thinking, evaluating, recommending, however, most of that valuable information doesn’t end up in the medical record. With ’95 and ’97 E&M Guidelines in the past Practitioners need to be aware of the new guidelines and how important staying compliant must be.

Evaluation and management guidelines do not just include bullet points, time components or body systems. There is a way to educate your practice on these updated rules that will clear up confusion and create opportunity for improved documentation and potential for higher reimbursement.

Documentation and medical records are more important than ever for reimbursement and medical necessity. Insurance Payers are scrutinizing and auditing more and more as the months go by. Don’t miss this extremely informative webinar by industry expert speaker Stephanie Thomas to learn how to take your documentation to the next level and protect yourself from costly audits.

Webinar Objectives

During the webinar Stephanie will take a deep dive into the most up-to-date Evaluation and Management guidelines beginning with the medical decision-making table. Often providers base their CPT code selection on the # of diagnosis a patient may have or perhaps the amount of documentation they are able to pull through from previous chart notes. Medical decision-making based on the complexity of the patient and visit is a much more consistent way to not only code visits, but also to document. Many real-world examples will be utilized to show the simplistic manner in which these guidelines can work to the advantage of any practice.

Internal auditing is very important. Many practices don’t use this tool to identify issues early, which can be a devastating mistake. Audits are a quick and productive way to be sure your team understands guidelines and documentation justifies charges billed. Stephanie will provide tips on how to build an audit plan and how to implement as well.

Webinar Agenda

  • Summary of Changes
  • Medical Decision Making
  • Complexity
  • Time Component
  • Auditing
  • Teamwork

Webinar Highlights

  • What “makes up” a level 4 office visit (99204, 99214)
  • Plan of care importance
  • Breakdown of “medically appropriate history and exam”
  • Time spent with patient vs MDM-what is best?
  • Self-auditing records
  • Time component-staff time or Provider only?
  • EHR record cloning tips on how to avoid issues
  • Medication management clarification

Who Should Attend

  • Medical office staff
  • Administrators
  • Office managers
  • Pre authorization staff
  • Billing staff
  • Billing managers
  • Front desk staff
  • Medical assistants
  • CNA’s
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