Writing or Erasing the EHR Documentation Dilemma
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
Two ways to register for this event
This event was recommended by 96.44 % of your peers.You rated this event:
- Individual access only
- 1 CEU
- Online streaming via desktop or mobile downloading for offline viewing
- Access broadcast, downloadable podcast (MP3), presentation slides, Q&A and any other event materials
Annual Webinar Subscription
- 40+ live webinars each year (including this event)
- 1 CEU per webinar (40+ annually)
- Online streaming via desktop or mobile device, or downloading for offline viewing
- Access to a growing number of on-demand events (includes over 120+ on-demand recordings)
- A library of topics to choose from: coding, billing, auditing, compliance, and practice management, covering more than 20 specialties
- For more details visits our annual subscription page
*prices are for members, non-members add $155 per person