Summary
In this episode, Sean and Terry discuss various aspects of E&M audits, focusing on compliance, documentation, and the importance of accurate patient records. They share personal anecdotes and insights into the challenges faced by healthcare providers in maintaining proper documentation and the implications of upcoding. The conversation emphasizes the need for thoroughness in patient care and the potential pitfalls of inadequate documentation.
Takeaways
<ul>
 <li>E&M audits are crucial for compliance in healthcare.</li>
 <li>Accurate documentation is essential to avoid upcoding.</li>
 <li>Independent historians play a significant role in patient history.</li>
 <li>Providers must review and sign off on clinical staff documentation.</li>
 <li>Using templates should not replace personalized patient care.</li>
 <li>Documentation must reflect the actual patient encounter.</li>
 <li>EKGs require proper interpretation and documentation to be valid.</li>
 <li>Healthcare providers should avoid generic notes in patient records.</li>
 <li>Communication between providers is key to effective patient care.</li>
 <li>Incomplete documentation can lead to legal and financial repercussions.</li>
</ul>

Summary In this episode, Sean and Terry discuss various aspects of E&M audits, focusing on compliance, documentation, and the importance of accurate patient records. They share personal anecdotes and insights into the challenges faced by healthcare providers in maintaining proper documentation and the implications of upcoding. The conversation emphasizes the need for thoroughness in patient care and the potential pitfalls of inadequate documentation. Takeaways E&M audits are crucial for compliance in healthcare. Accurate documentation is essential to avoid upcoding. Independent historians play a significant role in patient history. Providers must review and sign off on clinical staff documentation. Using templates should not replace personalized patient care. Documentation must reflect the actual patient encounter. EKGs require proper interpretation and documentation to be valid. Healthcare providers should avoid generic notes in patient records. Communication between providers is key to effective patient care. Incomplete documentation can lead to legal and financial repercussions.

Summary
In this episode, Sean and Terry discuss various aspects of E&amp;M audits, focusing on compliance, documentation, and the importance of accurate patient records. They share personal anecdotes and insights into the challenges faced by healthcare providers in maintaining proper documentation and the implications of upcoding. The conversation emphasizes the need for thoroughness in patient care and the potential pitfalls of inadequate documentation.
Takeaways
<ul>
 <li>E&amp;M audits are crucial for compliance in healthcare.</li>
 <li>Accurate documentation is essential to avoid upcoding.</li>
 <li>Independent historians play a significant role in patient history.</li>
 <li>Providers must review and sign off on clinical staff documentation.</li>
 <li>Using templates should not replace personalized patient care.</li>
 <li>Documentation must reflect the actual patient encounter.</li>
 <li>EKGs require proper interpretation and documentation to be valid.</li>
 <li>Healthcare providers should avoid generic notes in patient records.</li>
 <li>Communication between providers is key to effective patient care.</li>
 <li>Incomplete documentation can lead to legal and financial repercussions.</li>
</ul>

Episode 348 - #TerryTuesday - E&M Challenges and Solutions

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals.
The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape.
Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency.


When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”!


Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, The American Academy of Professional Coders and Practice Management Institute.

Business

Sean is the host of “The Compliance Guy” a live production dedicated to the intersection of regulatory compliance and the business of medicine. The show provides timely, accurate, and easy to digest information to healthcare professionals. The show features interviews of industry leaders, government officials, and others helping to shape the healthcare landscape. Sean M. Weiss (AKA – The Compliance Guy) has been an industry respected name for more than 25-years. A physician and health system advocate, Sean engages with clients to ensure a “level-playing-field” and due process when allegations and/or accusations of impropriety are leveled by a payor or government investigation agency. When Sean is not engaging in administrative, civil and criminal matters on behalf of more than 30 nationally recognized law firms and clients, he is serving as a third-party compliance officer for a dozen organization across the country ranging in size and specialty to ensure a “Culture of Compliance”! Sean is a proud member in good-standing with the National Society of Certified Healthcare Business Consultants (NSCHBC), American Health Lawyers Association (AHLA), National Alliance of Medical Auditing Specialists (NAMAS), and the American Academy of Professional Coders (AAPC). Sean holds (CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM) national certifications from the Health Care Compliance Association, The National Alliance of Medical Auditing Specialists, The American Academy of Professional Coders and Practice Management Institute.

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Episode 348 - #TerryTuesday - E&M Challenges and Solutions

Episode 348 - #TerryTuesday - E&M Challenges and Solutions

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