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This informational presentation is designed to provide an overview of current industry challenges impacting health care providers and staff for appropriate documentation and coding of office-based patient encounters. The presenter will discuss current documentation struggles, including the use of EHR technology, and look at potential future concerns for compliance and audit risks.
An overview of practical issues for health care providers, as well as coding, billing and auditing professionals involved with professional services (Part B) settings, will be provided. This presentation will cover the essentials of medical services documentation and the guiding principles that are the basis for documentation and coding practices in a physician office setting. The presenter will discuss changes to the health care delivery model, emphasizing quality reporting tools as health care shifts from fee-for-service to a fee-for-value model.
This presentation will also review:
- Documentation basics, including key components of the record, impact of the care setting and teaching facility considerations.
- Unique patient care conditions, including wellness visits.
- Specific documentation differences for inpatient and teaching physician services.
- Examples of common problems that create audit and compliance risk, including the use of technology to streamline the documentation process.
Who Should Attend
Clinicians and ancillary staff responsible for coding, billing and auditing functions associated with physician professional provider services.
This program has been approved for two continuing education units (CEUs) for use in fulfilling the continuing education requirements of the American Information Management Association (AHIMA). AAPC: AHIMA CEUs are accepted from programs sponsored by AHIMA national offices and the state AHIMA branches hour for hour; program approved for two CEUs. Provider approved by the California Board of Registered Nursing; provider number 05474 for two contact hours. Certificates of attendance will be provided upon completion of event evaluation. HIM Domain: Domain type(s): Clinicial Data Management. Event Number WEB115