Empowering Providers with Accurate Documentation & Compliance

This presentation delivers a comprehensive refresher on E/M auditing, focusing on the 2023–2025 guidelines and best practices for accurate coding, documentation, and medical decision-making. It’s designed for healthcare professionals, coders, and compliance officers seeking to improve audit outcomes and reduce risk.

Key Topics Covered

1. Medical Decision Making (MDM)

• 3 core elements: Problems Addressed, Data Reviewed, Risk Assessment
• MDM levels: Straightforward, Low, Moderate, High
• Examples of MDM scenarios and CPT code mapping

2. Common Audit Blunders

• Misinterpretation of documentation

• Overlooking complexity in patient management
• Inadequate use of MEAT (Monitor, Evaluate, Assess, Treat)

3. Best Practices for Documentation

• Impactful and relevant clinical notes
• Use of independent historians
• Proper credit for tests, orders, and discussions

Benefits of Attending

• Improve coding accuracy and reimbursement outcomes
• Reduce compliance risk and audit penalties
• Gain confidence in applying current E/M guidelines
• Learn how to support medical necessity through documentation

Who Should Attend

• Physicians & Advanced Practice Providers
• Medical Coders & Billers
• Compliance Officers
• Revenue Cycle Managers

Supporting Materials

• E/M Audit Decision Trees
• CPT Code Reference Tables
• Documentation Checklists
• Case Studies & Real-World Examples