American College of Chiropractic Consultants Seminar

October 12-14, 2023

Chicago Marriott Oak Brook

1401 W. 22nd Street
Oak Brook, IL 60523

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Evaluation and Management (E/M) Documentation and Coding Workshop

Presented by Kathy (KMC) Weidner, MCS-P, CPCO, CCPC, CCCA

Thursday October 12th from 1:00 pm – 5:00 pm

With streamlining being a goal of the Patients over Paperwork initiative, federal agencies have been directed to “cut the red tape” to reduce burdensome regulations. January 1, 2021, marked a significant change in the Evaluation and Management (E/M) Coding for Outpatient Services with updates in January 2023. These were the first major changes to E/M service coding since 1997. While it may be more simplified and streamlined, chiropractors must have a keen understanding of the requirements for E/M coding and documentation. This is a code set that is used daily in the office and carries with it one of the highest error rates of any code set used in healthcare. Knowledge of the CMS E/M Documentation Guidelines supports well-informed providers and CAs alike with in-depth knowledge of what documentation must be present in order to report E/M services. This session will include live auditing, workshopping, and coding and documentation review and training..

At the end of the course, participants will be able to:

    • Use E/M auditing tools to identify which level of E/M code is appropriate for the documentation provided
    • Properly code E/M services for both new and established patients
    • Audit E/M visits in the context of a compliance audit and determine error rates and required training for providers
    • Apply the new algorithm to appropriately code for E/M services under the new model
    • Determine the elements that count as Time-Activities and how to calculate appropriately
    • Establish protocol to determine Medical Decision Making (MDM) element of E/M encounter
    • Discover how to still demonstrate Medical Necessity in E/M documentation
    • Evaluate the necessary elements to properly document established patient re-evaluations of all types
    • Identify appropriate evaluation and management services to justify continued care, assess progress, and discharge from this active care when the time is right
    • Determine the necessary components of documenting the transitional diagnosis and treatment plan after a periodic re-evaluation
    • Recognize the fundamentals of documenting the assessment of change since the last evaluation as it applies to federal regulations in Medicare