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Writing or Erasing the EHR Documentation Dilemma

Presenter Jill M Young, CPC, CEDC, CIMC
Broadcast Date 6/27/2018
Time 10:00am PT / 11:00am MT / 12:00pm CT / 1:00pm ET
Presentation Length 60 minutes
Price $65 (Non-members $85)
Writing or Erasing the EHR Documentation Dilemma Webinar

Learn more about this event

Is your provider documenting the elements of the physical exam performed or are they deleting items from a “normal” template to represent the work? Many providers document a detailed or comprehensive level Review of Systems (ROS) and Exam on all patients – because the template is there. The template has 9 or more elements which may be more than the selected E&M level requires. They then spend significant time reviewing complete ROS or comprehensive Exam to erase any items that are listed as normal. They then spend additional time re-documenting what the patient actually has. If they miss “erasing” an item, the chart will be in conflict and most likely fail on audit. This lecture will show a methodology for documenting what the E&M code requires in a forward thinking environment. The provider can always document more. This approach is a time saver, is compliant and results in relevant documentation of the patients. 2-5-8 represents the exam elements of office E&M services level 3,4 and 5 and helps define the methodology.


Documentation of E&M

  • What is needed for level of service?
  • Carriers have indicated the will dis-regard information charted that is not relevant to the chief complaint of the patient
  • Over documentation may be suspicious
Jill M Young, CPC, CEDC, CIMC

About The Author

Jill M Young, CPC, CEDC, CIMC

Jill has over 30 years of medical experience with a diverse background in all areas from clinical to billing, and many different physician specialties. She has been published in a wide range of periodicals and presented many audio conferences and webinars. She gives educational lectures for the Michigan State Medical Society and other national organizations, including The Coding Institute (TCI) and Eli Research. Jill also presents AAPC workshops and often speaks at AAPC’s National Conference. She is an original member of the AAPCCA board of directors and loves meeting AAPC members at chapter meetings, National Conference, and in her everyday work as a consultant.

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