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This session will go through the basics of auditing a medical record for evaluation and management services for any provider speciality. This will include choosing the level of service utilizing an auditing tool for history, exam, and medical decision making. We will review the changes made to the documentation requirements for E/M services in 2019 so that attendees understand the rationale behind the changes and will be able to apply them to their offices' policies, procedures and workflows.
There have been changes made the documentation requirements for office visits for 2019, but many are unsure about how to apply the guidelines that have been in place for many years. This webinar takes a complete look at the 3 elements of any evaluation and management (E/M) service, history, examination, and medical decision making and what are the required documentation criteria for each, as well as apply the concepts of obtaining the level of service documented. If this information is used in assigning the level of service for an E/M visit, the medical record should be able to pass an audit.
Senior Director of Coding Education for Healthcare Information Services, a physicians revenue cycle management company. She is a former member of the American Academy of Professional Coders (AAPC) National Advisory Board, and has served on several other boards for the AAPC. She is also the founder of her local chapter of the AAPC. Her experience is primarily in the specialties of Orthopedics, Rheumatology, and Hematology/Oncology. She has been a speaker for many conferences, including the AAPC National Conferences and Workshops, Community Colleges, audio conferences, and Local Chapters. Lynn became a CPC in 1993, and a Certified Instructor in 2002, and a Certified Orthopedic Surgery Coder in 2009.