Clear and concise medical record documentation has always been important. However, the 2021 evaluation & management (E&M) coding updates demonstrate that the documentation in a medical record is more important than ever to provide patients with quality care, ensure accurate and timely payment for the services provided, mitigate malpractice risks, and help physicians and other providers evaluate and plan the patients treatment and maintain the continuum of care. Just as medicine has changed over the years so must your documentation. During this session, we will review the importance of medical record documentation; discuss the improved Subjective, Objective, Assessment and Plan (SOAP) note; explain how documentation affects coding & reimbursement; share examples of poor documentation; and discuss tips on appealing denials.

Learning Objectives

• Describe the importance of medical record documentation.
• Discuss the improved SOAP note.
• Explain how documentation affects coding and reimbursement.

Presenter
Cindy Penkala, CMM, CMPE

Disclosure Information
In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, ACOFP requires that individuals in a position to control the content of an educational activity disclose all financial relationships with any ineligible company. ACOFP reviews the disclosed relationship and mitigates all relevant financial relationships to ensure independence, objectivity, balance, and scientific rigor in all their educational programs.
All individuals in control of the content of this activity have no relationships with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Accreditation and Credit Statements
The American College of Osteopathic Family Physicians (ACOFP) is accredited by the American Osteopathic Association (AOA) to provide osteopathic continuing medical education for physicians.

ACOFP designates this program for a maximum number of 0.75 AOA Category 1-A credits and will report CME with the extent of the physician’s participation in this activity.

Disclaimer
This program is sponsored by ACOFP for educational purposes only. The material presented is not intended to represent the sole or best medical interventions for the discussed diagnoses, but rather is intended to present the opinions of the authors or presenters that may be helpful to other practitioners. Attendees participating in this medical education program do so with the full knowledge that they waive any claim they may have against ACOFP for reliance on any information presented during these educational activities.

Questions
To submit questions to the presenter(s) please send them to elearning@acofp.org and include the conference and course title so we can direct them correctly.

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