This curriculum will teach you all you need to know about performing and documenting inpatient E/M services. This program includes the relevant Rational Physician Coding course, plus individual modules for the most common inpatient encounters. Using clinical examples, we show you step-by-step how to select the correct level of care for every encounter and then how to document the visit as expeditiously as possible. This curriculum is made up of 9 individual video tutorials and has been approved for 8 hours of AMA PRA Category 1 CME Credit™
Author/Presenter: Peter R. Jensen, MD, CPC | Director of E/M Compliance Yale New Haven Hospitalist Service
Format: Self-paced video tutorial (runs in the browser of any PC, Mac, tablet or smart phone)
Target Audience: Physicians, Physician Assistants, Nurse Practitioners, Coders, Office Managers
Total Number of Modules: 9
Subscription Term: 1 year
CME: AMA PRA Category 1 Credits™ (8 hours)
Accreditation: Yale University School of Medicine Continuing Medical Education
Rational Physician Coding for Hospitalist E/M Services: If you want to understand outpatient E/M coding for hospital patients, start here. This course reviews the E/M coding changes from 2021 and 2023, which are still in effect today. Learn how to apply the most current E/M guidelines to the most common hospital encounters. This course will take you step-by-step through the process of quantifying your medical decision-making. The updated rules for coding based on time are also discussed. Learn how to select the “correct” level of care for all encounters, then how to complete the documentation as expeditiously as possible to save time and ensure compliance. Run time: 48:05
CME: 1 AMA PRA Category 1 Credit™
Initial Hospital Care Services: The initial hospital care codes are now used for reporting initial hospital care services for both inpatients and observation care patients. The level of care is now driven by time or the medical decision-making needed for the visit. This course will show you how to add up time for initial hospital care services and how to calculate your medical decision-making so you can always select the correct code for these services. Using clinical examples, we illustrate exactly what documentation is needed for each level of care for admission H&Ps. The latest guidance for reporting prolonged services with these encounters is also discussed.
Run time: 54 minutes. CME: 1 hour AMA PRA Category 1 Credit™
Hospital Progress Notes: Thes subsequent hospital care codes are now used for reporting subsequent hospital care services for both inpatients and observation care patients. The level of care is now driven by time or the medical decision-making needed for the visit. This course will show you how to add up time for subsequent hospital care services and how to calculate your medical decision-making so you can always select the correct code for these services. Using clinical examples, we illustrate exactly how to add up your medical decision-making for all levels of care and then how to document each visit as efficiently as possible to maintain compliance. The latest guidance for reporting prolonged services with these encounters is also discussed.
Run time: 54 minutes. CME: 1 hour AMA PRA Category 1 Credit™
Emergency Department E/M Services: This course reviews the documentation requirements for emergency department E/M services. The previous requirements for specific levels of history and physical exam have been discarded. The level of care is now driven solely by the medical decision-making needed for the visit. This course will show you how to calculate your medical decision-making so you can always select the correct code for these services. Using clinical examples, we illustrate how to choose the right code for each visit and then how to perform and document a medically appropriate history and exam.
Run time: 49 minutes. CME: 1 hour AMA PRA Category 1 Credit™
Inpatient Consult Services: This course reviews the rules and documentation requirements for reporting inpatient consult services. The level-1 inpatient consult code (99251) has been deleted, which leaves us with four levels of care for these services. The previous requirements for specific levels of history and physical exam have been discarded. The level of care is now driven by time or by the medical decision-making required for the visit. These courses will show you how to calculate your medical decision-making so you can always select the correct code for these visits. Using clinical examples, we illustrate how to document each level of care for outpatient consult services. The appropriate codes to use when performing “consults” on Medicare patients in the hospital setting is also discussed.
Run time: 53 minutes. CME: 1 hour AMA PRA Category 1 Credit™
Critical Care Services: Learn how to apply the most recent E/M coding updates and guidance to critical care services. Did you know that Medicare adds up critical care time differently than the AMA CPT Manual? Can critical care be a split/shared service? What happens when I cross midnight while performing critical care? Can two doctors in the same group aggregate their critical care time on the same date? Get the answers to these questions and more in this concise, clinically based presentation featuring the latest updates and clarifications regarding critical care services.
Run time: 24 minutes CME: 1/2 hour AMA PRA Category 1 Credit™
Prolonged Services: This course reviews the rules for coding for prolonged services in both the outpatient and inpatient settings. There are two methodologies for coding for prolonged services, one endorsed by the AMA and one endorsed by Medicare. Medicare will ONLY pay for their G codes for prolonged services. This course will take you through the requirements for prolonged services for all outpatient and inpatient encounters.
Run time: 30 minutes CME: 1/2 hour AMA PRA Category 1 Credit™
Initial Nursing Facility Care Services: This course reviews the rules and documentation requirements for reporting initial nursing facility care services. There are three levels of care for these services. The previous requirements for specific levels of history and physical exam have been discarded. The level of care is now driven by time or by the medical decision-making required for the visit. These courses will show you how to calculate your medical decision-making so you can always select the correct code for these visits. Using clinical examples, we illustrate how to document each level of care for initial nursing facility care services. The rules for reporting prolonged services in the nursing facility setting are also discussed, as well as the most recent guidance on nursing facility discharge services.
Run time: 57 minutes. CME: 1 hour AMA PRA Category 1 Credit™
Subsequent Nursing Facility Care Services: This course reviews the documentation requirements for reporting subsequent nursing facility care services. There are four levels of care for these services. The previous requirements for specific levels of history and physical exam have been discarded. The level of care is now driven by time or by the medical decision-making required for the visit. These courses will show you how to calculate your medical decision-making so you can always select the correct code for these visits. Using clinical examples, we illustrate how to document each level of care for subsequent nursing facility care services. The rules for reporting prolonged services in conjunction with subsequent nursing facility services are also discussed.
Run time: 59 minutes. CME: 1 hour AMA PRA Category 1 Credit™