1. Basics of Coding and Medical Record Documentation Presented by Angie Nolan, CHA, CPC, CPC-I, PCS, RMA HIMS Educator Banner Medical Group

3. Basic Documentation

4. Functions of the medical record

5. Key components of E&M codes

6. Basic E&M coding-new patient services

7. Basic E&M coding-established patient services

9. Serves as a legal document

10. Serves as a compliance document

11. Outlines the patient’s care and treatment rendered

13. Dictation for documentation should be efficient and thorough

14. Date and time should accompany all entries

16. Supports “medical necessity”

17. Reduces medical errors and professional liability exposure

18. Reduces audit exposure

19. Facilitates claims review

20. Supports insurance billing

21. Provides clinical data for education

22. Provides clinical data for research

23. Promotes continuity of care among physicians

25. History of present illness-4 of 8 elements

26. Review of systems-up to 10 or more organ systems (or a few systems and statement “all other systems have been reviewed and are negative”)

27. Past, family, and social history-all 3 elements (non-contributory is not acceptable documentation)

28. Examination

29. For a general Multi-System Exam - At least 2 bullets from each of 9 body systems or areas

30. Or for a single organ system exam please see the 1997 documentation guidelines for requirements for that organ system

31. Medical decision making

32. Straightforward

33. Low

34. Moderate

36. A best defense is always a good defense

37. Document what you do and do what you document

39. CMS Evaluation and Management Services Guide-2008

40. CMS 1995 Documentation Guidelines