Documentation of an E&M Office Visit – 5 Things Needed for a Good Note

Documentation of an Evaluation and Management (E&M) note is something that has changed dramatically in the past 4 years. Physicians no longer need the “comprehensive history and physical” they are accustomed to documenting.  And yet they continue to spend more time than needed documenting bullet points of a physical exam when something more focused is all that is required.

This webinar will cover what is needed for a good note that is compliant with moderate medical decision making (level 4 office or level 2 hospital).  These tips in giving the listener 5 good things that need to be in the documentation in a short and succinct note.  This will help the provider in having a note that is appropriate for the level of service billed but will also save the provider time in documenting it.

As we are finally getting information from payers, through their audits, on what documentation they require for the changes that occurred to E&M services in 2021 and 2025.  Using that information, we are able to help providers develop new habits they need in providing documentation of the work they are performing.  Being concise and direct will also help them to be more efficient. 

Webinar Objectives

Physicians and other providers continue to over document their E&M visits using old requirements for what is needed.  They are also wasting their time in some situations in documenting much more than is required while under documenting in other areas because of the new rules.

Giving providers an understanding of what is required for E&M visits is so important in helping them during their busy days of taking care of patients.

Webinar Agenda

• Brief overview of Evaluation and Management Medical Decision Making Table
• Brief overview of documentation of Evaluations and Management visit using time to select level of service.
• Update of payer policies we know regarding documentation of Evaluation and Management visits.
• Focused discussion of what 5 things should be in a note that has compliant documentation

Webinar Highlights

• 5 things for a good note
• What information no longer needs to be documented in the record
• What information is imperative to be documented in a complaint note
• What are key differences in required documentation of a level 3 and level 4 office visit
• What valuable information are the Medicare MAC’s giving us regarding prescription drug management

Who Should Attend

Coders, Billers, Auditors, Physicians, Nurse Practitioners, Physician Assistants