Inpatient/Observation Services: Important Documentation Guidelines
Physicians, Podiatrists, Dentists, Fellows, Residents, Nurse Practitioners, Physician Assistants, Athletic Trainers and Coding Professionals.
- Implement the three key components of medical documentation to substantiate levels of E&M codes.
- Distinguish between a new patient from an established patient.
- Establish medical necessity throughout the E&M documentation and code selection.
- Adhere to CMS guidelines in order to avoid undercoding and overcoding.
Tyling M. Batista, CPC, CEMC, CPMA
Physician E&M Compliance and Education Lead
BHMG Quality and Performance Department
Due to the non-clinical nature of the content discussed, the speakers have no relevant financial relationships to disclose. This CME activity will not cover content that would involve products or services of commercial interests. Therefore, no opportunity exists for a conflict of interest based on the financial relationships of faculty and those persons in control of content. Since these relationships are not relevant, no disclosure information was collected.
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.
Baptist Health South Florida designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 0.50 AMA PRA Category 1 Credit™
- 0.50 Florida Board of Athletic Training
- 0.50 General certificate of attendance
- 0.50 Florida Board of Dentistry
- 0.50 Nurse Practitioners
- 0.50 Florida Board of Podiatric Medicine
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