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Risk-Based Coding the Path to Successful E&M Documentation
This presentation about documentation & coding is designed to take a  complex issue and make it … logical meaningful useful
Risk-Based E&M Coding
Complexity of Medical Decision-Making
Risk ?
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Data ?
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
DX / MGT ?
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Complexity / MDM ?
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Some Examples
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Complexity of Medical Decision-Making
Evaluation and Management Services…
History…
Chief Complaint (CC)…
Chief Complaint (CC)…
History of Present Illnes
Review of Systems (ROS) levels…
Review of Systems (ROS)…
Review of Systems (ROS)…
Past Medical, Family and Social History
Level of History ?
Level of History
Physical Examination (PE)…
Body Systems/Areas
Physical Examination (PE)…
Physical Examination (PE)…
Physical Examination (PE)…
Requirements for 99244/245
ICD 9-CM Coding
ICD 9-CM Coding
Properly Documenting Consultations
Properly Documenting Consultations
Properly Documenting Consultations
Properly Documenting Consultations
General Principles of Medical Records Documentation
Congratulations, Training Session Completed !
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