Audit-Proof E/M Coding: Medical Necessity & Documentation Mistakes

Course Description

Accurate documentation is more than a regulatory requirement — it is the foundation of medical necessity, compliant coding, and defensible reimbursement. In today’s audit-driven environment, incomplete or nonspecific documentation can lead to denied claims, recoupments, and compliance risk.

Join this comprehensive training designed to strengthen your understanding of medical necessity, Evaluation & Management (E/M) coding principles, and documentation best practices. Led by a nurse, certified professional coder, and ICD-10 trainer, this session bridges the gap between clinical care and coding compliance. You will gain practical insight into best documentation, what auditors look for, and how to ensure your notes accurately support the level of service billed.

This webinar will include real-world documentation examples, common pitfalls, and clear strategies to improve note quality. The session will conclude with a Learning Lab where attendees can apply concepts to sample cases and strengthen their documentation skills in real time.

Whether you are a provider, clinician, coder/biller, compliance office or administrator, this training will equip you with the tools needed to chart with clarity, code with confidence, and reduce compliance risk.

Learning Outcomes

• Define medical necessity and explain its role in supporting compliant reimbursement and audit defensibility.
• Identify the required components of Evaluation & Management (E/M) documentation under current guidelines.
• Differentiate between compliant and non-compliant documentation using real-world examples.
• Demonstrate how to link patient symptoms, assessment findings, and medical decision-making to the level of service billed.
• Apply ICD-10-CM coding principles to ensure diagnostic specificity and alignment with documented conditions.
• Analyze common documentation deficiencies that increase audit risk and claim denials.
• Construct a complete, patient-specific progress note that supports medical necessity, reflects individualized care, and aligns with the assessment and plan.

Areas Covered in the Session

• Understanding medical necessity and how it supports compliant reimbursement.
• Applying current E/M guidelines to confidently select the correct level of service.
• Connecting documentation to revenue integrity and audit protection.
• Identifying common audit red flags and documentation vulnerabilities.
• Strengthening medical decision making to support billed services.
• Improving ICD 10 specificity to align diagnoses with clinical findings.
• Avoiding documentation pitfalls that lead to denials and recoupments.
• Creating clear, patient specific notes that reflect individualized care.
• Preparing documentation that stands up to payer and regulatory scrutiny.
• Participating in a hands-on Learning Lab to apply concepts in real time.
• Live Q&A Session

Recommended Participants

• Providers and Physicians
• Clinicians and Nursing Staff
• Medical Coders and Billing Specialists
• Compliance Officers and Risk Managers
• Practice and Clinic Administrators
• Revenue Cycle and Operations Teams
• Documentation Improvement and Quality Staff
• Federally Qualified Health Center Leaders
• Rural Health Clinic Teams
• Clinical Educators and Trainers

Shellie Sulzberger, LPN, CPC, ICDCT-CM, is a Licensed Practical Nurse and a Certified Professional Coder. She received her Bachelor of Science degree in Business Administration from Mid America Nazarene University. Ms. Sulzberger received her nursing license in 1994 and was a practicing clinician at Saint Luke’s Health System for several years before transferring to the internal compliance/audit area. She became credentialed as a Certified Professional Coder in 1996 and assisted Saint Luke’s Health System with performing medical record chart audits to verify the accuracy of the internal coding and claims processing.

Ms. Sulzberger spent approximately six years as a coding/billing consultant with national accounting and consulting firms (BKD, Grant Thornton) before becoming the President of Coding & Compliance Initiatives, Inc. (CCI) in April 2003. Ms. Sulzberger assists her clients with improving their operational performance in a variety of critical outcome areas, including coding/billing, corporate compliance, charge capture processes, etc. Ms. Sulzberger works with a variety of health care providers including hospitals, physician practices, and rural health clinics in their daily compliance and operational activities.

A substantial amount of Shellie’s time is spent providing education with the physicians and internal coding staff regarding opportunities for the clinic to improve its current documentation and coding practices, which impact both the revenue and compliance risk of the facility.

Shellie works extensively with federally qualified health centers across the country (along with physician practices, rural health clinics, and hospitals), serving as an independent auditor and compliance resource to improve documentation quality, coding accuracy, workflow, and revenue cycle performance. She works collaboratively with the National Association of Community Health Centers (NACHC) and State Primary Care Associations (PCA), including speaking at Revenue Cycle 360 and several Primary Care Associations’ annual conferences and other educational conferences.

She assists legal counsel with research, investigation, and her expert opinion. She also provides clinical education in the areas of patient management and medical record documentation. She attends many physician and other staff meetings to offer updates and to act as a liaison for the health care provider.

Ms. Sulzberger presents locally and nationally on coding topics, as well as developing specialized training programs to meet the needs of her clients. Shellie works with the front office and back office revenue cycle team members, focusing on education regarding E/M and ICD-10 coding and billing guidelines and coding/billing-related processes that improve compliance and cash flow.

She emphasizes communication between the billing team and the providers and clinicians about the “downstream” impacts of incorrect coding.

Shellie personally works with 10 health centers annually regarding documentation, coding, and billing processes and serves as an education resource for several State PCAs each year.

Shellie is credentialed through the American Institute of Healthcare Compliance as a Certified ICD-10 Trainer.

Additional Information