Making Everything Equally Efficient.
Finally! An E&M manual for providers that speaks the same language as the providers who author the notes.
The goal of this manual is to empower providers to make the proper level of service selection while actively performing patient care as opposed to mastering coding services.
Finally! An E&M manual that speaks the same language as the providers who author the notes.
The goal of this manual is to empower providers to make the proper level of service selection while
actively performing patient care as opposed to mastering coding services.
What To Expect From Inside Our Manual
- True patient encounters
- By Level of Service
- Clinical Service in Action
Medical Decision Making
- What do we want from this project?
- What do we have to achieve to make this project successful?
- Critical success factors: KPIs
- Effective use of History Components Exam in 2021 DG
- Time Chart
- Qualification Statement
- AMA Activities List
- Time Carve Outs
- Teaching Physicians Services
- Split-Shared Services time only)
- Prolonged CMS
- Prolonged AMA
Medical Record Documentation
- Documentation Techniques
- Multiple Entries
- Macros, Templates, Copy & Paste
- Late Entry
- Signature Guidelines
- Documentation Timelines, Attestations, Addendums & Corrections
- Attestation Statement Requirements
- Determining Medical Necessity
- Chart for Acute
- Chart for Chronic
- Time & Medical Necessity
- Findings Overall
Straightforward and direct guidance.
A resource and reference tool to assist in creating compliant and purposeful documentation without the fillers.
Healthcare providers face many challenges. It seems that oftentimes a higher emphasis is placed on documentation and compliance than is placed on concerns related to medical malpractice and even patient care itself. We hope that we can help push through the tasks of documentation by streamlining efficiencies that allow compliance in revenue, while optimizing patient care.
This manual is written NOT by a peer, a fellow clinician. Rather it is written by the auditor who is tasked with understanding how to “grade” the encounter, break it down, understand the components of it, and when components may be deficient, train for improvements. Clinical care is YOUR area of expertise… This is OUR area of expertise, OUR specialty, the area we should excel in the most. Coding and billing by virtue is always evolving as our rules shape and shift with changes in disease, technology, even politics, and sometimes it even seems with the wind; however, there are evergreen areas that are rarely changed. E&M has been one of those areas for some 25 years. However, that all changed in 2021. This training manual will take you through these changes. Our goal is to be a guide, and also to provide some hands-on skills development, if you’re up for the challenge.
The focus of this manual is specifically office/clinic based E&M services focusing on the code set 99215-99202. This E&M manual for providers does, at times, discuss other code sets, but the core focus will be 99215-99202. Even more fundamentally, the key function of this manual is documentation.
The purpose of this manual is to bridge the gap between the encounter and the documentation, and to assist the clinician in meeting our common goal-
Learn how to streamline your documentation and in-turn optimize patient care.