Level 3 or Level 4 Office Visits – What’s the Big Difference in Documentation?

From a day to day perspective, most providers are hoping to get to a level 4 visit in the office.  The changes to Office and Other Outpatient Services codes from 2021 are still mis-understood.  To help your physician appropriately document a level 4 office service this audio conference will identify the most common mistakes seen in under-documenting this service.  Certain words are all that are needed in some situations that can make that difference.  You just need to know them to help your provider understand what is required for that moderate level of Medical Decision Making (MDM) in order to bill a level 4 vs a level 3 office visit.  AND the same concepts hold true for hospital services as well.  Listen and learn how to help your providers recognize and compliantly document  level 4 visits.

KEY LEARNING OBJECTIVES: 

What are the key differences that are needed in documentation to get to that moderate (vs low) level of medical decision making? The key to discerning the difference between moderate and low medical decision making is understanding where physician documentation of certain components falls short.  Understanding why Acute isn’t the same as Severe; or what systemic manifestations means; or how to code if you have 3  or 4 chronic illnesses instead of the 2 listed on the table are all questions to be answered during this conference.    

TARGET AUDIENCE:

• Office coders
• Auditors
• Managers
• NP
• PA and physicians         

MAIN POINTS TO BE COVERED:

• When words matter:  Acute vs chronic; or Acute vs Severe; defining a complication; what is an uncertain prognosis
• What is needed to show Medication Management?
• What documentation is needed for a test interpretation?
• When can you use a spouse’s comments as a historian’s?