Evaluation and Management Services – Chart Auditing Tips

Event Information
Product Format
Prerecorded Event
Linda Smith, CPC, CPC-I, CEMC, CMBS
60 minutes
Product Description

E&M Services Auditing: Tips to Correctly Interpret Documentation and Coding Guidelines


Auditing of evaluation and management services can be difficult due to the varying interpretations of the documentation and coding guidelines. Having a good plan and a good process for documentation is essential to ensure a successful E/M audit. It's important to be able to assess your E/M Auditing skills.

In this presentation, expert speaker Linda Smith will offer solutions to deal with those interpretations and offer guidance to build the auditors confidence as they perform audits. The objective of this presentation is to provide medical office staff responsible for auditing of evaluation and management services with valuable tips for performing this task.

Session highlights:

  • Gathering reliable resources to support your auditing decisions and development of auditing policies/procedures
  • Selecting the audit tool that will works best for your organization
  • How to have a good plan and a good process
  • How to assess and understand your organization’s E&M auditing skills
  • Understanding the objective of an audit and gathering reliable resources
  • Identifying elements of the chart audit that may hold varying interpretations and creating a defensible audit
  • Key points of the AMA guidelines for reporting evaluation and management (E/M) services
  • Key points of the CMS documentation guidelines
  • How to access the CMS E/M utilization data

 Session Preview:

  • The E/M Audit process
  • Selecting the right audit tool
  • Understanding AMA and CMS documentation guidelines
  • HPI Elements
  • The concept of Medical necessity
  • Examples of presenting problems for new and existing patients
  • A discussion of clinical examples
  • E/M utilization benchmarks
  • Missing or poorly documented key components of the E/M service
  • E/M Code 99211
  • Review of Systems as a part of E/M services
  • 1995 and 1997 exam documentation
  • Modifier 25

Who should attend

Coders, auditors and other medical staff who may be involved in the auditing of evaluation and management services.

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About Our Speaker

Linda Smith - Preventive Medicine Services Coding Expert

Linda Smith is the founder of MedOffice Resources, an organization established to provider resources and development services to medical office staff in the New York State area.

Linda has over 35 years of experience in the healthcare industry. Throughout that time, the healthcare industry has gone through dramatic changes. Medical offices have experienced reduced reimbursements for services and an ever-increasing focus on regulatory guidelines...   More Info
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