Learning Objectives

Module 1 – Introduction to CPT E/M Categories

Be able to identify the categories of E/M codes.

Be able to apply the CPT E/M category guidelines.

Be able to define the common symbols and terms used in the CPT book.

Be able to accurately assign Evaluation and Management codes by category.

Module 2 – Assigning E/M Levels Based on Key Components & Time

Be able to understand the 1995 documentation requirements.

Be able to understand the 1997 documentation requirements.

Be able to identify the differences between 1995 and 1997 guidelines.

Be able to identify history of present illness (HPI) terms and definitions.

Be able to identify terms in documentation and assign them to the HPI.

Be able to understand and apply the HPI documentation guidelines.

Be able to identify the review of systems (ROS).

Be able to understand and apply the review of system documentation guidelines.

Be able to identify past personal, family, social, history (PFSH).

Be able to identify terms in the documentation and assign them to the PFSH.

Be able to assign the overall history using the history elements.

Be able to identify organ system and body areas of the examination.

Be able to understand and apply the examination guidelines appropriately.

Be able to identify medical decision making.

Be able to understand and apply the medical decision making elements.

Be able to assign Evaluation and Management codes by level.

Module 3 – Evaluation and Management Associated Modifiers

Be able to identify when an E/M modifier is warranted.

Be able to understand the usage of E/M associated modifiers.

Be able to understand and apply appropriate modifier to correct E/M codes.

Module 4 – Teaching Physician of Residents & Students

Be able to understand definitions of teaching physician rules.

Be able to identify and apply the documentation requirements for a teaching physician when residents are involved in patient care.

Be able to identify acceptable teaching physician attestation statements.

Be able to identify and apply supervision documentation requirements.

Be able to identify and apply time–based codes documentation requirements.

Be able to identify and apply primary care exception documentation requirements.

Be able to provide an overview of Medicare coverage of services provided by interns and residents.

Be able to identify situations in which a teaching/attending physician's presence is required when residents are involved in patient care.

Be able to determine the proper way to report for a resident's involvement in patient care (including the appropriate use of modifiers).

Module 5 – Non–Physician Practitioner (NPP) E/M Services

Be able to identify when to apply 99211 services and who can report them.

Be able to identify and understand professional incident–to rules.

Be able to determine whether a particular non–physician practitioner service qualifies for "incident to" coverage.

Be able to understand and apply split and shared visits.

Module 6 – Audit Strategies

Be able to understand comprehensive error rate testing (CERT) findings and how they may impact your practice.

Be able to ask the right questions to perform data mining of E/M services.

Be able to understand the importance of E/M bell curve profiling and how to use the information as a guide for compliance and revenue opportunities.

Be able to understand the function and focus areas of recovery audit contractors (RAC) for physician services.

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Learning Objectives

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