When Office and Other Outpatient Services saw their major change in documentation rules in 2021, there were many new guidelines and rules to try to understand and adjust to.  When the changes to other Evaluation & Management codes occurred, following suit, in 2023, we still did not understand well all the changes that had been made.  Now adding on to the initial set of changes were a few additional ones.  Finally, as we had waited patiently, carriers, through releases on FAQ, articles and audits, gave us little titbits of information to help clarify what was acceptable to them for documentation in these new rules for E&M services.

As we are now in the fourth year since the initial changes were made to E&M documentation guidelines, we are gaining valuable information for what phrases like “problem addresses”, independent report” and “prescription drug management” mean for provider’s documentation. 

Providers seem to be having difficulty stopping old habits of documenting complete history and physical exam elements even though that requirement has changed.  Understanding the changes that were made that can save the providers significant time in their documentation and make auditing of those records significantly easier with reasonable changes in documentation.  One of the major issues is provider’s seeming reliance on drop down documentation and pre-populated templates instead of, often times, quicker narrative documentation.

Webinar Objectives

The session will walk through the Elements of Decision-Making table.  Requirements of the differing levels of service (i.e. low and moderate) will be reviewed.   Discussions of frequently seen incorrect documentation will occur along with offering documentation tips to be utilized in educating providers. 

Webinar Agenda

Beginning with problems addressed from the first column of the Elements of Medical Decision Making, documentation rules and policies will be discussed.  Then, a discussion of what the complicated items are in the middle column or amount and/or complexity of data to be reviewed will occur.  Explaining what the nuances are for historian and personal interpretation are in documentation will occur next.  Finally, the risk column will be discussed.  First explaining that this is the risk of the treatment to the patient and showing the difference it is from the risk from the illness will occur.  Then other elements such as prescription drug management, social determinants of health will be discussed along with others.

Webinar Highlights

• Table of the Elements of Medical Decision Making
• Description of each of the three columns
• Documentation requirements of each
• Time based code selection and its documentation requirements
• Pitfalls in documentation, what simple notations can tank a note and cause it to fail audit

Who Should Attend?

Coders, Billers, Auditors, Compliance, Office Manager, Office Administrator