Provider Documentation Training

Our experience at so many private, hospital-owned, and academic practices leads us to anticipate that the quality of the reports and medical records that constitute the source documents for coding may be suboptimal.  Across all specialties, we often find documentation deficiencies in the various source documents.  Physicians and other providers often do not know which data elements must be separately documented and are critical for proper coding and the assignment of specific modifiers.  Add to this the inherent complexity of the E&M coding parameters that make it difficult for a busy physician or mid-level provider to select the correct code from an often densely printed charge-ticket.  These circumstances can preclude the ability to code a specific service, or can require it to be coded at a lesser-valued code in order to be compliant with the rules and regulations.

We feel that the first step in eliminating this problem is training the physicians and mid-level providers on proper medical record documentation.  Our goal is not to turn the doctors into coders, but to give them the information and tools they need use every day to accurately and completely report their services.  Over-and-over we see that the greatest documentation and compliance problems arise from what the physicians do not know.  This will improve the quality of patients’ medical records, and will give the coders –be they the physicians themselves or the practice’s staff, or TCN’s coders– and your entire billing-and-collecting staff, a much improved chance to optimize the revenue potential of each-and-every patient-care service provided by the physicians.

All of our training programs are specialty-specific, so we suggest they be held as single specialty presentations.  This assures the physicians in the audience that everything being discussed will be pertinent to them.  There is no limit to the number of physicians and staff who can attend our documentation training presentations.  The Director of our E&M Coding and Auditing Division developed TCN’s own specialty-specific workbooks that include the E & M codes, critical care, the dictation of a useful operative report, and more.  She will personally give all on-site training presentations.  She has taught this program hundreds of times to thousands of physicians across the country.

The E&M training sessions generally cover a substantial amount of material, so, if desired, we will work with the practice’s leadership to customize the training presentation specifically to the client’s needs.  If a coding audit is completed prior to the training sessions, those findings will be integrated into the program to make it even more meaningful to the individual providers.  The full program and questions-and-answers can take 2+ hours to deliver and includes, among other topics:

  • An Overview of the Evaluation & Management system
  • The components of an E&M service:
    • History of Present Illness:
      • History of the Present Illness
      • Chief Complaint
      • Review of Systems
      • Past Family & Social History
    • Physical Examination
    • Medical Decision Making
    • Counseling
    • Coordination of Care
    • Nature of the Presenting Problem
    • Time Driven Codes
  • The 1995 and 1997 Documentation Guidelines
  • Understanding and Selecting Levels of Service
  • Documentation Requirements to Support Levels of Service
  • Multisystem and Single organ system Exams/Services
  • Definitions of New and Established Patients and Documentation Requirements
  • Consultations and Documentation Requirements:
    • Outpatient
    • Inpatient
    • New Medicare Rules Eliminating Consult Codes
  • Inpatient Services and Documentation Requirements
  • Observation Services and Documentation Requirements
  • Concurrent Care and Documentation Requirements
  • Critical Care Services and Documentation Requirements
  • ASC’s and Other Sites of Service
  • Suggested Contents of an Operative Report
  • Co-Surgery and Team Surgery
  • Global Packages for an Operation: What Is Included?
  • Modifiers and the documentation they require, including, among others:
    • Increased Procedural Services (22)
    • Staged Procedures (58) -vs.- unplanned returns to the OR (78) –vs.- unrelated operations (79)
    • Bilateral (50) –vs.- LT and RT
    • Discontinued Operations (53)
    • E&M services and operations on the same day by the same doctor
  • Fracture Care:  Surgical or E & M Coding?
  • Teaching Physician Rules and Regulations (if appropriate)
  • Care Management Services
  • Medicare Regulations
  • Preventive Medicine
  • ABN requirements
  • E&M Services With Separate Medical/Surgical Procedures
  • …. And more.

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