The Documentation Improvement Guide to Physician E/M

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The Documentation Improvement Guide to Physician E/M

Product Code: DIGEMM

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Give physicians a crash course in the documentation of E/M services

Physicians who provide E/M services must document the necessary clinical information to support their medical decision-making. This is where CDI specialists play an important role, and The Documentation Improvement Guide to Physician E/M can help. This reference guide helps CDI specialists  explain to physicians how complete and accurate documentation benefits their E/M payments, prevents medical necessity denials, and provides the information they need to document correctly.

This handbook offers the perfect portable reference guide for CDI specialists to educate physicians about E/M documentation. This handbook is provided in packs of 10 so CDI specialists can distribute copies to physicians during documentation improvement education sessions or in response to physician questions and requests for additional information.

This reference guide will help CDI specialists:

  • Better understand the complex guidelines that affect physician payment for E/M services
  • Explain the importance of documentation to physicians beyond hospital reimbursement
  • Clarify the purpose of  queries and how responding to them benefits physicians’ payments and public profiles
  • Encourage physicians to provide adequate documentation that will reduce the number of denials for lack of documented medical necessity
  • Access a comprehensive list of additional online resources to further aid them in their important role

Take a look at the table of contents:

Chapter 1: E/M Documentation
Chapter 2: Components of E/M
Chapter 3: Chief Complaint
Chapter 4: History of Present Illness
Chapter 5: Review of Systems
Chapter 6: Past, Family, and Social History
Chapter 7: Physical Examination
Chapter 8: Medical Decision-Making
Chapter 9: Amount and Complexity of Data
Chapter 10: Critical Care
Chapter 11: Medical Necessity and Clinical Documentation

Meet the Author:

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, is a health information management (HIM) professional with extensive experience in Current Procedural Terminology (CPT®) and International Classification of Diseases, 9th Revision (ICD-9). He focuses on the role of medical record clinical documentation in charge capture, reimbursement, quality and outcomes studies, and establishing medical necessity.

Krauss has served as a revenue cycle consultant, senior coding/reimbursement consultant and recovery audit contract project leader, manager of revenue systems and coding, revenue cycle coordinator and HIM director, vice president of coding and documentation compliance, coding instructor, coding technical advisor, data quality manager, HIM manager and health system analyst, clinical coding specialist, and medical records technician.