On Demand: Complex E/M Coding and Documentation-Presentation Slides

Presentation Slides

Pdf Summary

The document discusses various topics related to complex E/M coding and documentation. It provides information on claiming CEU credits, coding CEU certificates, and offers a brief recap of the top problem areas in 2021 and 2023 E/M guidelines. The document also covers documentation in the medical record, including the use of standard abbreviations and note auditing by the OIG. It outlines key concepts of the 2021 E/M guidelines and emphasizes the importance of meeting key elements for determining the level of service. The document further explains documentation expectations, differentiates between new and established patients, and discusses the use of external sources and problem addressed notations. It highlights the importance of medical decision making and the inclusion of chief complaints, assessment, diagnosis, and plan in the medical record. The document also provides information on split/shared services in the hospital setting, critical care, and prolonged services. It explains the use of time in billing and the expectations for care coordination and communication in the medical record. The document concludes by discussing the implementation of a new CMS complexity code and provides a disclaimer regarding the information presented.

Keywords

complex E/M coding

documentation

CEU credits

2021 E/M guidelines

medical record

problem areas

chief complaints

medical decision making

billing

CMS complexity code