This presentation will include an overview of coding Evaluation and Management encounters and how to properly document the History, Exam and Medical Decision Making.

Why should you attend: One of the most misunderstood aspects of documentation and E & M code level is Medical Decision Making (MDM). Very few coders receive instruction in the MDM scoring system using by many government and independent auditors. Even few providers are aware that these guidelines even exist. MDM is the number one reason for Downcoding encounters. In addition, very few EMR help score MDM and most allow an easy upcode that could result in refunds and fines during an audit.

Areas Covered in the Session:

• Fundamentals of an Evaluation and Management Encounter.
• Overview of the Medical Decision Making process and documentation Requirements
• The Marshfield Clinic Medical Decision Making Point system as adopted by Medicare Carriers and the OIG.
• Apply the concepts learned to working case studies
• Why 99.9 percent of EMR software packages will upcode your encounter.
• The importance of Medical Decision Making in 2010 due to Medicare’s dis-allowance of the E & M Consultation Codes.
• Specific documentation elements needed to quantify the level of MDM.
• How to explain the MDM process without scaring the doctors with the complexity of the Point System.
• Strategies on how to implement proper MDM documentation and coding in your clinic.
• Internet and additional Resources Jeff will provide a thorough review of this process, using real-life examples.

Who Will Benefit:

• Coders
• Coding Manager
• Coding Auditors
• Compliance Director
• Providers