Evaluation & Management
Coding and Documentation
Guidelines for Neurosurgery
BENEFITS OF PARTICIPATING IN A VIRTUAL MEETING
- Remote learning allows time-pressed surgeons and their staff stay abreast and ahead of coding issues without the cost or hassle of travel.
- Active learning while participating in live question and answer sessions.
- Earn 2.5 CEU credits.
- KZA experts present to you in the comfort of your home or office.
- Quality KZA tools are downloadable, making implementation easy.
Evaluation & Management 2.0 Workshop
2021 E/M Guidelines for Neurosurgery –
Thursday March 18th | 4:00 – 7:00 PM Central
This 3-hour course analyzes the 2021 CPT E/M guidelines and presents them in the distilled understandable format for which KZA is known. Building on what providers are currently doing, the restructured elements of Medical Decision Making and Time are broken down and explained.
There will be “hands on” coding of E/M notes as well as plenty of time for Q&A. Participants will have the opportunity to cement understanding and leave empowered with a “To Do List” for successful transition.
We will provide you with key documentation tips to optimize your coding and documentation. These tips can assist in building your electronic health record templates to adequately address the Medical Decision Making that takes place during an office visit. They will be used during the course to cement education points to prevent inadequate documentation.
The audit tool is an edited version of the CPT guidelines restructured for easy use and education. The course will use the tool to review notes and ‘score” them based on the MDM that is documented.
- Gain a greater understanding of the overall 2021 changes to E/M, including the subtle nuances and reasons behind the revisions
- Understand the revised times and Medical Decision Making processes for all office-based E/M codes starting Jan. 1, 2021
- Learn what the performance of history and exam “only as medically appropriate” means
- Learn what activities can be counted when selecting the level of service based on time for 2021 office-based services
- Understand revisions to code descriptors for 99202-99215 and which codes have been deleted
- Understand the role of ancillary staff with the “patients over paperwork” theme throughout the new coding process
Note: This course does not cover existing E/M guidelines which will be used, in 2021, for office consultation codes (9924x) and inpatient service codes.
- Name three elements required for Medical Decision Making in 2021 for new and established patient visit Evaluation and Management (E/M) codes.
- Differentiate Time ranges and requirements in the current and 2021 E/M guidelines.
- Apply the correct guidelines depending on the category of E/M service.
*You will receive and initial confirmation email after registering and the login information for the meeting approximately 1 week in advanced. Please email email@example.com if you have questions.
$499 per participant
2020 AAPC Accreditation
This program has the prior approval of AAPC for 2.5 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.
Credit is available after completion of an evaluation and a 40 question test.
The workshop content is copyrighted property of KarenZupko & Associates, Inc. Any rebroadcast, reproduction, or other use of the pictures, content and accounts of this workshop or the accompanying handout without the express written consent of KarenZupko & Associates, Inc. is prohibited.
*agenda subject to change
Comparing Original to 2021 Guidelines for New & Established Outpatient Visits
- Where did this new information come from?
- Converting prior E/M code selection and guidelines to 2021 E/M code selection and guidelines
- Key elements: Medical Decision Making and Time
- What about History and Exam documentation?
- Incorporating medical necessity into 2021 E/M documentation
2021 Using Medical Decision Making to Determine Level
- Incorporating the Newly Redefined Medical Decision Making Elements
- Element #1: Number and Complexity of Problems Addressed
- Problems, Illnesses & Injuries: how are they defined?
- Stable vs chronic
- How is the complexity of the problem determined?
- Counting the number of problems. What constitutes a separate problem?
- Exercises: Determining number of problems in Neurosurgery
- Element #2: Data to be Reviewed and Analyzed
- Defining Data Category 1
- What is included as an external note?
- What is a unique data test?
- What is a unique source?
- Who qualifies as an independent historian and how is this role documented?
- Exercises: Identifying unique tests and notes in Neurosurgery
- Defining Data Category 2
- Documenting independent interpretation
- Defining Data Category 3
- What constitutes a discussion of management or tests?
- Who qualifies as an external or other source?
- Exercises: Documenting unique tests and notes in Neurosurgery
- Defining Data Category 1
- Element #3: Risk of Complications and/or Morbidity or Mortality of Patient Management
- Defining level of risk: what does CPT say?
- Documenting level of risk. Do the current risk table examples still apply?
- How do test and treatment decisions impact co-morbidity and risk?
- Exercises: Determining level of risk in Neurosurgery
- Documentation Tips by Element: Problems Addressed, Data Reviewed/Analyzed, and Risk
2021: Using Time to Determine Level of Service
- What is included in the new ranges?
- What work and whose work is counted when time is used?
- Using prolonged service codes with time codes in 2021
- Exercises: Using Time to determine level of service in Neurosurgery
Exercises: Documentation Review Using 2021 Guidelines
- Auditing documentation with the new tool
Documentation Tips to a Successful Transition
Operational Steps to a Successful Transition
Consultant and Speaker