Evaluation and Management Coding and Documentation 101

• Understand the meaning of a Chief Complaint
• The HPI revisited. History of Present Illness is one of the most important elements of E/M
• Review of Systems (ROS) and the documentation requirements to allow for credit
• CPT Documentation Guidelines Discussed and Interpreted
• Time vs. Documentation elements
• PFSH needs how many elements for a level 4?
• 1995 or 1997 E/M Guidelines should we be using?
• Doesn't MDM drive the CPT code?
• We will show you how to pick a level of service 
• We will make sure you are compliant with your documentation efforts.

What questions will be addressed?

• New vs Established patient, Is the 3-year rule the only one to go by?
• We are a specialty physician practice, are there different rules for us?
• Are rules for NPP's different than rules for Physicians?
• What E/M codes can RN's bill for?
• Is scheduling a patient for a stress test automatically a moderate level of service?
• Interactions with the physicians and what they need to do to be compliant.

Who Should Attend?

• Front Office Staff
• Office Managers
• Back office staff
• physicians
• administrators
• mid-level providers