NYHIMA Webinar Series - Physician Documentation Excellence Session 2 - 2023 Evaluation & Management - The "Standards of Documentation"
Tuesday, May 20, 2025, 12:00 PM EDT
Category: Online Education Session
Session 2 - 2023 Evaluation & Management - The "Standards of Documentation" In this session, we will delve into key aspects of Evaluation and Management (E&M) coding, emphasizing the critical role of documentation and clinical decision-making in accurate and compliant coding practices. We will begin with an overview of the 2023 Evaluation and Management guidelines, exploring how they influence both hospital and outpatient settings. A significant portion of the discussion will focus on medical necessity, addressing the essential role that physicians play—not just within the hospital environment, but in every stage of patient care. By enhancing the quality of documentation, particularly within H&P (History and Physical) and progress notes, we can improve E&M coding accuracy and ensure compliance. We'll also explore opportunities within clinical decision-making (CDI) and how it directly impacts coding and reimbursement. Interactive case studies will provide attendees with hands-on experience in leveling H&P and progress notes, offering practical insights into common challenges and solutions. Through this session, you'll gain a deeper understanding of how to optimize documentation and leverage E&M coding for better outcomes in both clinical and financial realms. Overall Objectives
SpeakerGlenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM Glenn Krauss is a well-recognized & respected subject matter expert in the revenue cycle with an emphasis & focus upon collaborating & working closely with physicians in promoting, advocating for, educating & achieving sustainable improvement in clinical documentation that accurately reflects & reports the communication of fully informed coordinated patient care. He possesses 25 plus years of progressive practical hands-on experience in clinical coding & documentation improvement, subscribing to the philosophy that quality of medical record documentation strongly correlates with overall quality of care & the overall achievement of a high performing revenue cycle. What sets Glenn apart in the clinical documentation improvement arena is the recognition of clinical documentation effectiveness, accuracy, completeness & contextual consistency as fundamentally integral with all components of the revenue cycle. $39 NYHIMA Members and free for Student Members
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