Coding and Documentation for Minor Procedures

Accurate coding and documentation for minor procedures can make a major difference in compliance, reimbursement, and audit readiness. This engaging and practical webinar is designed to help providers, coders, and billing professionals confidently navigate the nuances of reporting minor procedures performed in the office or outpatient setting.

Participants will begin by gaining a clear understanding of global periods for minor procedures, including what services are included and when separate reporting may or may not be appropriate. 

The webinar will also focus on strengthening documentation practices to support commonly performed minor procedures. Attendees will learn how to clearly and effectively document the procedure, medical necessity, and any related evaluation performed, ensuring that the record supports accurate code selection.

A key highlight of the session is learning how to distinguish when it is appropriate to bill an Evaluation and Management (E/M) service in addition to a minor procedure. Through real-world examples, participants will explore the concept of a “significant, separately identifiable” E/M service and understand proper modifier usage, including when it is—and is not—justified.

Whether you're looking to reduce denials, improve documentation quality, or strengthen compliance, this webinar will provide actionable insights and practical tools you can apply immediately in your practice.

Learning Outcomes

• Identify the global period for minor procedures, including services included and exceptions for separate reporting.
• Use appropriate verbiage in documentation of common minor procedures performed in an office or other outpatient setting.
• Distinguish when an Evaluation and Management (E/M) code can be billed in addition to a minor procedure.
• Strengthen documentation practices to clearly support the medical necessity and performance of minor procedures.
• Understand the concept of a “significant, separately identifiable” E/M service and its application to minor procedures.
• Apply proper modifier usage for billing E/M services with minor procedures, including when it is—and is not—justified.
• Recognize common coding errors and documentation deficiencies that lead to denials for minor procedures.
• Implement strategies to improve audit readiness for minor procedure coding and documentation.
• Analyze real-world scenarios to clarify complex coding and documentation challenges for minor procedures.
• Develop internal workflows to ensure accurate and compliant reporting of minor procedures.
• Identify the impact of accurate coding and documentation on reimbursement for minor procedures.
• Differentiate between minor procedures and more complex surgical procedures in terms of coding and documentation requirements.

Areas Covered in the Session

Recommended Participants

• Provider
• Clinician
• Coder/Biller
• Compliance Officer or Administrator
• Practice Manager
• Medical Assistant
• Nurse Practitioner
• Physician Assistant
• Revenue Cycle Specialist
• Healthcare Consultant
• Office Staff involved in patient intake and scheduling
• Auditors
• Patient Financial Services Staff
• Clinical Documentation Improvement (CDI) Specialists
• Health Information Management (HIM) Professionals
• Educators in healthcare administration and coding

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.

• Internet Speed: Preferably above 1 Mbps
• Headset: Any decent headset and microphone which can be used to talk and hear clearly