The Art of Coding Office and Hospital Visits


*agenda subject to change

7:00AM — 8:00AM

Check-in and Breakfast (provided)

8:00AM — 9:00AM

E/M Office and Outpatient Guidelines in 2021

  • 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?
  • 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?
    • Defining Data Category
      • Documenting independent interpretation
    • Defining Data Category 3
      • What constitutes a discussion of management or tests?
      • Who qualifies as an external or other source?
  • 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

9:00AM — 10:00AM

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?

10:15AM — 11:00AM

Prolonged Services Codes

  • Coding for prolonged services for new and established patient office and outpatient services
  • CPT code 99417 and HCPCS code G2212
  • Time thresholds and documentation

11:00AM — 12:00PM

Coding for E/M Services in the Hospital Setting

  • Selecting the accurate category of code for services performed in a facility setting
  • Selecting the correct level of service using the 1995/1997 Documentation Guidelines

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Coding Coaches