Coding and Documentation: The Importance of Accurate Documentation for Patients and Providers

Coding and Documentation: The Importance of Accurate Documentation for Patients and Providers

Release Date: 05/24/2017
Expiration Date: 05/24/2020
Format: Internet Activity Enduring Material

Statement of Need/Program Overview

This educational activity is designed to improve accuracy of documentation and coding among physicains and healthcare providers. With the continued advancement of electronic health records (EHRs), there are new challenges to maintaining documentation integrity. Improving documentation and coding techniques is important from a risk management perspective because without the appropriate management and guidelines in place, EHRs can compromise patient care and reimbursement.

Target Audience

The target audience for this activity is Medical Mutual's provider physician groups and related healthcare professionals.

Educational Objectives

After completing this activity, the participant should be better able to:

  1. Summarize the areas of evaluation and management coding impacted most by electronic records including the use and misuse of modifiers
  2. Explain the required guidelines for use of mid-level providers, inclusive of how to bill for services
  3. Outline the correct use of scribes in medical record documentation
  4. Cite 2-3 examples of pitfalls encountered with the use of electronic documentation shortcuts
  5. Discuss the value of audits and the legal implications of insufficient/improper documentation

Accreditation Statement

Medical Mutual is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

Medical Mutual designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For information about the accreditation of this program, please contact the CME Team at 800.662.7917 or at .

Instructions to Receive CME Credit

In order to successfully complete the activity, participants must score 70% on the post test at the end of the activity and complete the course evaluations. Each participant has a maximum of three attempts to score a 70%. Successful completion is supported by a 70% pass rate at the end of the course, proving competency on the content of the activity.

Faculty and Disclosures

Medical Mutual requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity.

All identified conflicts of interest are thoroughly vetted by Medical Mutual for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The following reported no relevant financial relationships or relationships to products or devices that they or their spouse/life partner have with commercial support interests related to the content of this activity:

  • Patricia A. Markus, JD, Nelson Mullins Riley & Scarborough LLP (Faculty)
  • Sharon Clayton, BSN, MSN, MBA, CPC, Firm Logic of Womble Carlyle Sandridge & Rice LLP (Faculty)
  • Mary Alice Culler, Senior Risk Consultant, Medical Mutual (Reviewer)
  • Sharon Nichols, Senior Risk Consultant, Medical Mutual (Planner)
  • Lauren Hauser, Senior Risk Management Coordinator, Medical Mutual (Planner)
  • Whitley Paige, Risk Managment Coordinator, Medical Mutual (Planner)


Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

Not a guarantee that using information provided will prevent a claim against you or your practice.

Technical Requirements

This activity is best experienced using the most current browser (or one back) of Firefox, Chrome, Safari, Internet Explorer, or Microsoft Edge. For all activities featuring audio you must have a sound card and speakers. To view graphic images and references that appear in separate "pop-up" windows, you must have JavaScript and session cookies enabled on your computer. Adobe Acrobat Reader may be required for certain activities.

Select the Continue button below to begin. You may return later if you are unable to complete the activity at this time.