E/M documentation for NPs and PAs
Documentation that defends itself.
E/M and medical decision making on the AMA framework, taught by an auditor who reviews these claims from the payer's side.
What the CMS data shows
The office visit gets audited, and NPs are on the list.
Finding 01
#2
Nurse practitioners rank second in the country for improper payments on established office visits, behind only internal medicine.
Finding 02
Fixable.
Most E/M errors come down to incorrect code selection and insufficient documentation. Not fraud, and both can be fixed at the note.
Source: CMS Medicare Fee-for-Service improper payment reports. Figures shift year to year.
Who this is for
You made the decision. The note has to show it.
01 · New to practice
Nobody taught you the note is a billing document.
Your program taught the visit. This shows you how the note becomes the claim.
02 · In practice
Your 99214s keep coming back as 99213s.
The care was there. The documentation didn't show the decision you made.
03 · Records requested
A payer asked for your notes.
Know what the reviewer reads first, before the letter arrives.
What the course covers
Seven modules, one working picture.
01
The outpatient revenue cycle
Front end, middle and back end, and where your note sits in it.
02
Where the provider fits
The parts of a provider note, and what each one supports on the claim.
03
Assessment and plan
The heart of MDM: the problem addressed, the decision made, the claim supported.
04
Medical decision making
Problems, data and risk, and how they add up to a supported level.
05
Time-based E/M
When the documented time supports the service, and when it doesn't.
06
Common NP documentation and E/M mistakes
Identify them, correct them, and stop repeating them.
07
Bringing it all together
The whole picture in one place, with a one-page self-audit for your own notes.
Who teaches it
I audit claims from the payer's side.
I review claims for Medicare, Medicare Advantage, Medicaid and commercial plans. On an office visit, the reviewer isn't asking whether you saw the patient. They're asking whether the note shows the decision.
This training is built in collaboration with Revenue Cycle Ready Academy™, so you learn from two coding and compliance auditors, not one.
Jesse Gallop · LPN, CDIP, CCS, CCS-P, CPMA, CPB, CRC, HCS-D, HCS-O
AHIMA-Approved Trainer · AAPC-Approved Instructor
What NPs and PAs ask first
Straight answers, before you ask.
01
"Isn't coding my biller's job?"
Your biller codes what the note supports. Only you can write the note.
02
"I already document everything."
Longer isn't better. The level comes from medical decision making or total time, not the length of the note.
03
"Will this make me code higher?"
It makes you code accurately. Sometimes that's higher. The goal is a level your note can defend.
Learn it live
Write the note the reviewer can't argue with.
Be the first to know when the next E/M training opens.