The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has performed auditing work and determined that 42% of claims for Evaluation and Management (E/M) services were incorrectly coded, which included both upcoding and downcoding (i.e., billing at levels higher and lower than warranted, respectively), and 19% were lacking documentation. They also noted that a number of physicians increased their billing of higher level, more complex and expensive E/M codes. Many providers submitted claims coded at a higher or lower level than the medical record documentation supports. This can put physicians and their practices at an increased compliance risk. On the flip side, if physicians are billing E/M codes at a lower level than warranted then they are potentially leaving legitimate reimbursement on the table.

E/M coding can be confusing, complex and difficult for physicians and their staff. This workshop will break down the 1995 and 1997 documentation guidelines for E/M services from the perspective of a physician. Your presenter is an MD who has been a certified coder for almost 20 years. This workshop is unique in the fact that not only will Dr. Wolf present the coding guidelines for E/M services, but he will provide clinical insights into those guidelines. He will share with you how a doctor thinks and works in the context of the E/M guidelines.

Seminar Fee Includes:
AM-PM Tea/Coffee
Seminar Material
USB with seminar presentation
Hard copy of presentation
Attendance Certificate
$100 Gift Cert for next seminar

Additionally, we will discuss the major announcement by CMS to adjust their requirements as it relates E/M guidelines.

Topics will include:

  • A review of key and recent compliance enforcement and settlements as they relate to E/M coding issues
  • The difference between the E/M guidelines concept of “medical-decision making” (aka MDM) and “medical necessity”
  • Clinical perspectives on key language and documentation physicians provide relating to patient history, physical exam and medical decision making.
  • Billing E/M services on coordination of care time.
  • The difference in CPT E/M coding categories and corresponding HCPCS “G-codes”
  • The 2019 proposed changes to E/M documentation rules.

Learning Objectives:

  • Comprehend the current regulatory enforcement environment as it relates to E/M services
  • Review recent settlement cases due to a lack of E/M documentation compliance
  • Analyze and apply the three key components of E/M coding
  • Understand the 1995 and 1997 documentation guidelines as they relate to history, physical exam and medical decision making.
  • Gain insights into the physician's clinical thought process in the context of E/M coding and documentation

Areas Covered:

  • Enforcement trends and government authority for E/M services under the U.S. False Claims Act
  • Medical History component of the 1995/1997 guidelines including chief complaint, history of present illness, past/family/social history, review of systems.
  • Physical Exam component of the 1995/1997 guidelines including body areas, organ systems and specialty specific exams.
  • Medical decision-making component of the 1995/1997 guidelines including number of diagnoses or management options, amount and/or complexity of data reviewed, and risk of complications and/or morbidity or mortality.
  • Medicare Claims Processing Manual, Chapter 12, Section 30.6 "Evaluation and Management Service Codes"
  • Modifiers related to E/M coding including documentation requirements for modifier -25, Significant and Separately Identifiable Services
  • E/M coding based on time
  • The 2019 proposed changes to E/M guidelines

Who will benefit:

  • Physician Practice Manager
  • Billing
  • Coding
  • Auditor
  • Compliance Officers
  • Physician practice partner
  • Physicians
  • Physician's Assistants
  • Nurse Practitioners
  • Nurses
  • Medical Assistants
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Day 01(8:00 AM - 4:30 PM)
  • 8:30 AM - 8:59 AM: Registration Meet & Greet.
  • 9:00 AM - 10:00 AM: Lecture 1
    • Seminar objectives review, expectations and scope.
    • Healthcare Enforcement Climate and Expectations/Requirements related to E/M Service’s
    • Settlement Examples from Lack of Compliance
  • 10:00 AM - 11:00 AM: Lecture 2
    • The Types of E/M Categories (New Patient, Established Patients, ED visits, etc.)
    • Overview of the three key components of E/M services
    • Overview of 1995/1997 guidelines
  • 11:00 AM - 12:00 Noon: Lecture 3
    • Compare/Contrast of History Differences between 1995/1997 guidelines
    • Compare/Contrast of Physical Exam Differences between 1995/1997 guidelines
  • 12:05 PM - 1:00 PM: Lunch
  • 1:00 PM - 2:00 PM: Lecture 4
    • Compare/Contrast of Medical Decision-Making Differences between 1995/1997 guidelines
    • Coding E/M Services on Time
    • Application: Code Actual Physician Documentation of E/M services
  • 2:00 PM - 3:00 PM: Lecture 5
    • Application: Code Actual Physician Documentation of E/M services
  • 3:00 PM - 4:00 PM: Lecture 6
    • Overview of 2019 CMS proposed changes to E/M Guidelines
  • 4:00 PM - 4:30 PM: Lecture 7
    • Questions and Answers
    • Dismiss and Departure
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CJ Wolf

CJ Wolf,
M.D, CHC, CCEP, CIA, Educator/Compliance Executive

C.J. Wolf, MD, M.Ed. has been involved in healthcare for over 20 years beginning with his years in medical school. Shortly after graduating Dr. Wolf made a career change to healthcare administration, reimbursement and compliance. He has worked in various coding, reimbursement or Chief Compliance Officer roles for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System and Merit Medical Systems. He currently is Sr. Compliance Executive at Healthicity.

Dr. Wolf has a passion for teaching and education. He has developed and taught curricula for adult employees seeking national coding certifications, trade workshops and seminars, and has served as adjunct faculty for Salt Lake Community College and currently is Faculty at Brigham Young University-Idaho and adjunct faculty at the University of Illinois at Chicago College of Medicine.

In addition to his medical degree from the University of Illinois at Chicago College of Medicine, Dr. Wolf holds a master of education (M.Ed.) from the University of Texas at Brownsville. He completed his B.S., magna cum laude, from Brigham Young University, Provo, UT.

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