2017 CMS Guidelines for Physician Documentation

Key Topics

• General principles of documentation
• Importance of proper physician documentation
• Documentation guidelines from Centers for Medicare & Medicaid Services (CMS)
• Documentation – legal aspects
• OIG recommendations
• Importance of auditing documentation
• Common documentation errors identified by the Recovery Audit Contractors (RAC) and Comprehensive Error Rate Testing (CERT) programs
• Improvement in clinical documentation
• How to identify incomplete documentation
• Common evaluation and management (E&M) services identified by CERT
• Insights on E&M medical necessity
• Medicare’s policy on medical necessity
• Legal ramifications of incorrect documentation

Who should Attend

• Office managers
• Auditors
• Coders
• Physicians