Baptist Health Coding and Documentation e-Learning Series

This course provides practitioners with a comprehensive overview of documentation and coding changes necessary to make immediate changes to E&M coding levels, in addition to the CMS changes and mandates for telemedicine services due to the current health crisis.

Target Audience

Physicians, Podiatrists, Dentists, Residents, Nurse Practitioners, Physician Assistants and Athletic Trainers.

Learning Objectives

  • Accurately identify the required documentation for the CMS-determined key components and contributing factors that support the E&M level for patient visits in both the outpatient and inpatient setting. 
  • Implement strategies discussed to achieve organizational accuracy rate standard for E&M coding. 
  • Adhere to the new CMS telemedicine guidance for service delivery, communication platforms, documentation expectations and coding requirements.
Additional information
Bibliography: 

CMS Documentation Guideline reference- CMS Guidelines for History, Exam and MDM, including Time and Counseling Department of Health and Human Services, Centers for Medicare and Medicaid Services, Evaluation and Management Services, August 2015 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Department of Health and Human Services, Centers for Medicare and Medicaid Services, 1995 Documentation Guidelines For Evaluation and Management Services https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

Department of Health and Human Services, Centers for Medicare and Medicaid Services, 1997 Documentation Guidelines For Evaluation and Management Services https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf

Department of Health and Human Services, Centers for Medicare and Medicaid Services, Transitional Care Management Services, March 2016             

Department of Health and Human Services, Centers for Medicare and Medicaid Services, CMS Manual System, PUB 100-04 Medicare Claims Processing, May 14, 2014 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

Department of Health and Human Services, Centers for Medicare and Medicaid Services, CMS Manual System, PUB 100-04 Medicare Claims Processing, August 26, 2011 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf https://medicare.fcso.com/FAQs/Answers/157200.asp

Department of Health and Human Services, Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners, Rev. 3476, March 11, 2016 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Resources: 

Baptist Health Employee: For any coding questions, please contact the Coding and Education Team at one of the following email addresses:
E&M Coding Questions: BHMGEandMcoding@baptisthealth.net
Orthopedic Coding Questions: DG-BHMGOrthoCoding@baptisthealth.net
CC Coding Questions: DG-BHMGHCCcoding@baptisthealth.net

Telemedicine Newsletter

April 2020 - Telemedicine
March 2020 - Orthopedic Documentation
December 2019 - New 2020 CPT Codes for Online Digital Services
November 2019 - CMS Changes to CY2020 and CY2021
October 2018 - Modifier 57
January 2018 - Consultation Coding
December 2017 - Home Health Certifications
October 2017 - Advanced Care Planning Services
July 2017 - The Facts About Transitional Care Management
June 2017 - Post-Operative Visits
May 2017 - Modifier 25
March 2017 - CMS Allows Prolonged Non-Face-to-Face E&M Codes
February 2017 - When Is An Established Patient... A New Patient?
January 2017 - Documenting HPI
November 2016 - Medical Decision-Making
October 2016 - How to Select your E&M Level
September 2016 - The Difference between Split Shared and Incident-to
September 2016 - Avoiding “Cloning” of your Documentation
August 2016 - Key Elements of E&M Service

Did You Know?

Blood Pressure Check
Coding For Heart Disease
Coding For Major Depression
Documenting the Status of Your Patient's Diagnosis
E&M Visits Immunization Administration
Modifier 57 vs 25
New Finalized CMS Changes
New Patient Office/Outpatient Consultation Visit
NPP in Assistant at Surgery
Orthopedic Coding Education
Signature Requirements for Injections
Teaching Physician Encounters Based on Time
 
Course summary
Course opens: 
07/01/2016
Course expires: 
06/01/2021

Tyling M. Batista, BSHA, CPC, CPCO, CPMA, CEMC
Manager, Documentation and Coding Improvement
Physician Practice Coding Education

Tyling M. Batista, BSHA, CPC, CPCO, CPMA, CEMC, indicated that neither she nor her spouse/partner have relevant financial relationships with commercial interest companies, and she will not include off-label or unapproved product usage in her presentations or discussions.

Non-faculty contributors and others involved in the planning, development and editing/review of the content have no relevant financial relationships to disclose. 

Disclosure Policy and Disclaimer

Baptist Health South Florida is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Baptist Health has been re-surveyed by the ACCME and awarded Commendation for 6 years as a provider of CME for physicians.
            

CMS Principles of Documentation Guidelines

 Baptist Health South Florida designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Chief Compliant and History Documentation for New and Established Patients

           
Baptist Health South Florida designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physical Examination Documentation for your Specialty

           
Baptist Health South Florida designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Medical Decision Making - One of the Major Key Components of E&M Coding

           
Baptist Health South Florida designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Time and Counseling/Coordination of Care Component

           
Baptist Health South Florida designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Review of E/M CPT Codes (Inpatient/Outpatient) and their Documentation requirements

           
Baptist Health South Florida designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Teaching Physician Documentation Guidelines 

           
Baptist Health South Florida designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Using a Scibe for Documentation

           
Baptist Health South Florida designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Split Share Documentation

           
Baptist Health South Florida designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Baptist Health Quality Network: Telemedicine Coding and Guidelines

Baptist Health South Florida designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

COMING SOON!
Baptist Health Medical Group: Telemedicine Coding and Guidelines

Baptist Health South Florida designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Baptist Health South Florida designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

 
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