Mastering Charting Habits for Compliance and Sustainable Billing
Mastering Charting Habits for Compliance and Sustainable Billing
As the maternity care landscape prepares for the 2027 transition in global billing, building a solid foundation in your documentation is more important than ever.
Join experienced billers Nancy Koerber and Marnie Cabezas every other Friday for this bi-weekly educational series. Designed for both clinicians and billing professionals, these sessions offer practical strategies and expert insights to help you navigate modern documentation requirements and maintain sustainable billing practices.
This series builds upon the AABC webinar "Notes that Pay Off." We recommend viewing this introductory webinar to get the most out of this series.
Access "Notes that Pay Off" Recording
Session 1: Evaluation & Management (E&M) Foundations
An in-depth look at E&M guidelines, standard documentation elements, and navigating patient complexity using frameworks like the ACOG prenatal complexity pyramid.
Session 2: Diagnosis Codes, Sequencing & Multiple-Code Claims
Strategies for navigating complex visits (such as dual preventive and problem-focused care), pairing ICD-10 diagnosis codes with CPT codes, using EGA Z-codes, and addressing patient financial responsibility.
Session 3: Strategic Code Selection
A practical guide to choosing the correct procedure codes and accurately determining the appropriate level for E&M CPT codes.
Session 4: Coding in Layers - Building Beyond the E/M
Capturing Everything You Actually Did
Building on our coding foundation, this session explores the additional clinical services that frequently occur alongside an E/M visit. We’ll identify the specific charting elements that support these services, best practices for documenting them, and criteria for separate reporting. From wellness and preventive care to in-house testing, labs, and patient counseling, we will connect daily documentation to appropriate CPT® and HCPCS codes while clarifying what is – and is not – separately billable.
Session 5: Procedures, Ultrasounds & Lab Services
Documenting Specialized Care
Expanding on core coding principles, this session shifts focus from traditional E/M charting to the specific documentation requirements for specialized procedures, including ultrasounds, and contraceptive care. We’ll identify the key charting elements needed to support these claims, distinguish procedure-specific notes from standard E/M records, and connect clinical care directly to CPT® and HCPCS coding. Finally, we’ll clarify when services are separately billable and how to navigate modifiers, bundling, and payer-specific rules.
Session 6: Labor & Delivery Documentation
Your care tells a story. Does your documentation capture the full picture?
Labor and birth can involve hours of assessment, hands-on care, clinical decisions, and changing plans. How do you make that work visible in the record – and document it with the clarity needed to support the services you provide?
Using real-world fictitious records, this session is a practical deep dive into charting with a procedure mindset. Experienced billers Nancy Koerber and Marnie Cabezas walk through how to map the intrapartum timeline, capture clinical reasoning, and navigate tricky scenarios like intrapartum transfers and labors crossing midnight.
Whether you provide care, review charts, or support billing, you’ll discover a clearer framework for documenting the skill, time, and decision-making involved in labor and delivery.
Session 7: Chart Check: Does the Note Make the Grade?
- Friday, October 9 at 1:00pm ET – LIVE
Real charts. Real coding decisions. Now it’s time to put your auditing skills to work.
We’ll start by walking through a sample chart together – evaluating the documentation to determine whether the note supports Medical Decision Making (MDM), Time-Based Billing (TBB), both, or neither, and most importantly, dissecting the why behind our “grade.”
Then, we’ll turn the tables. As a group, participants will review a new chart, determine what the documentation actually supports, assign the grade, and defend their reasoning. We’ll wrap up with plenty of time for Q&A, discussion, and review – including how to navigate areas where reasonable auditors may see things differently and strategies to make the documentation stronger.
Session 8: Front Desk 101 & Patient Navigation
- Friday, October 23 at 1:00pm ET – LIVE
The revenue cycle starts long before a claim is submitted – and your front desk is often where it begins.
This session focuses on the everyday front-office workflows that can make the difference between a smooth patient experience and problems that follow the practice all the way through billing and collections.
We’ll walk through scheduling and registration workflows, annual and preventive visit scheduling, insurance and demographic updates, referrals and authorizations, and communicating anticipated patient financial responsibility before services are provided.
We’ll also talk about one of the most important – and sometimes uncomfortable – front desk skills: having clear, confident conversations about coverage, deductibles, copays, non-covered services, self-pay amounts, and balances without asking administrative staff to interpret benefits or make promises about what an insurance company will ultimately pay.
Finally, we’ll look at communication between the front desk, clinical team, billing staff, and patient, and how a few well-designed workflows and scripts can prevent confusion, missed charges, scheduling errors, and avoidable patient frustration.
Session 9: Telehealth Services
- Friday, November 13 at 1:00pm ET – LIVE
A virtual visit is still a billable clinical encounter – and the documentation needs to stand on its own.
Telehealth has become part of routine care, but documenting a virtual encounter requires more than simply noting that the patient was seen by video or telephone.
We’ll review what should be captured in the record to support a telehealth service, including the modality used, patient and provider location when required, consent, participants, the clinical work performed, and the elements necessary to support the reported E/M service through MDM or time when applicable.
We’ll compare telehealth documentation with traditional in-person E/M documentation and discuss what changes – and what doesn’t – when the patient and provider are not physically in the same room.
We’ll also address common trouble spots, including audio-only versus audio/video encounters, payer-specific requirements, modifiers and place of service considerations, and distinguishing a true billable telehealth encounter from portal messages, brief communications, education, or other virtual interactions.
The goal: make sure the chart clearly demonstrates what happened, how the service was delivered, and why the service billed is supported.
Session 10: Supplies, Pharmaceuticals & Durable Medical Equipment (DME)
- Friday, December 4 at 1:00pm ET – LIVE
If you use it, administer it, dispense it, or send it home with the patient – there may be something to document, track, and potentially bill.
Clinical practices routinely absorb the cost of supplies, medications, and equipment simply because there isn’t a reliable process for moving those items from the clinical encounter to the claim.
In this session, we’ll look at the fundamentals of identifying, documenting, tracking, and capturing charges for billable clinical supplies, administered medications, and DME.
We’ll discuss the documentation trail needed to support these services – from the order and medical necessity to the specific item or medication, quantity, dosage, administration, dispensing, and other details required for billing.
We’ll also explore the distinction between items that are separately billable versus bundled into another service, the role of HCPCS and drug codes, and why payer policy matters before assuming that something used in the office can – or cannot – be billed separately.
Finally, we’ll connect the clinical side to the business side: inventory, charge capture, coding, documentation, and reconciliation, so that what leaves the supply cabinet or medication refrigerator doesn't quietly disappear from the revenue cycle.