Medical Documentation in the Era of EMRs and ICD-10

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Learn How to Populate the History, Physical Exams, Assessment and Plan Section of the EMR

Knowing how to properly document in the Electronic Medical Record will ensure the providers are documenting to the highest level of specificity for maximum reimbursement. It also decreases the chances of a negative finding during an audit. Proper documentation also allows for the transfer of information between parties to be much easier with less error. Along with this, ICD-10 requires more detailed clinical documentation, when compared to ICD-9, and many providers must be trained in regards to these requirements.

In this session, expert speaker Dr. Dreama Sloan-Kelly, MD, CCS, will share tips on how to populate the history, physical exams and assessment/ plan section of the EMR. You’ll also get tips on clinical documentation for documenting properly to support the most specific ICD-10 code which will be required effective Oct. 2016. Additionally, Dr. Sloan-Kelly will provide some tips on designing templates and avoiding common audit pitfalls.

Session Highlights:

  • Proper clinical documentation to support the most specific ICD-10 codes.
  • How to appropriately document in the history, physical exam, and assessment/plan so it is compliant while meeting all CMS documentation guidelines.
  • How to design a template that works for the group and ensures the note meets all compliance standards.
  • Pitfalls faced in audits – copy and paste; bringing forth old information; point and click; and more!
  • Avoiding negative audit findings in diagnosis coding and clinical documentation.
  • Communicating to doctors the importance of proper documentation rather than just pointing and clicking.
  • Who can document what in the EMR?

Session Snapshots:

  • What is the big deal with medical documentation?
  • Challenges with documentation
  • Documentation issues with doctors
  • Encouraging improved documentation
  • CYA + PYA = Financial Health
  • Documentation guidelines
  • Working with templates
  • Over-documentation issues
  • Documenting in the EMR
    • History
    • Physical exam
  • Medical Decision Making
  • Documenting for ICD-10
    • Recurring concepts in ICD-10
    • ICD-10 documentation tips
  • Compliance points to keep in mind

Who should attend

Practice Managers, Office Managers, Medical Billers, Medical Coders, MD, DO, NP, PA, Clinical Documentation Improvement Specialists, MR Auditors, Front Desk

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About Our Speaker

Dreama Sloan-Kelly - Healthcare and Medical Billing Coding Expert

Dreama Sloan-Kelly, MD, CCS has over 14 years of experience in the medical field. A graduate of Wellesley College and Tufts University School of Medicine, she has a varied background including clinical, billing, and coding. Dr. Sloan-Kelly is President/CEO of Kelly, Sloan, and Associates, LLC and speaks at various seminars and webinars, imparting her knowledge in an upbeat, matter of fact, manner. Her goal is get the...   More Info
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