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Course

Documenting Medical Decision Making

Instructor

Faye Grile, CCS-P, CDIP, CPC, COC, CPCO, CPMA, CEMC

Description

In this course, participants will gain a comprehensive understanding of the critical role of Medical Decision Making (MDM) in evaluation and management (E/M) coding. This course delves into the intricacies of MDM by exploring its three essential subcomponents: the assessment of presenting problems, the complexity of data review, and the level of risk involved. Participants will learn how to evaluate documentation to accurately assign MDM components to E/M codes, enhancing their ability to reflect the patient's severity and the provider's clinical judgment effectively. By combining these subcomponents, participants will master the art of determining the overall MDM level, ultimately leading to improved provider documentation and precise E/M code reporting.

Included Lessons:

  • What is Medical Decision Making (MDM)?
  • Subcomponent Determination - Elements of Medical Decision Making
  • Documentation Considered for Number and Complexity of Problems Addressed
  • Documentation Considered for Complexity of Data Reviewed Determination
  • Documentation Considered for Table of Risk Determination
  • Combining Subcomponents to Determine Overall MDM
  • Organizational Impact
CEUs available for the following credentials:

AAPC

COC, CPC, CPC-P, CANPC, CCC, CCPC, CCVTC, CDEI, CDEO, CEDC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CIC, CIMC, COBGC, COPC, COSC, CPB, CPCD, CPCO, CPEDC, CPMA, CPMS, CPPM, CPRC, CRC, CRHC, CSFAC, CUC

AHIMA

CCA, CCS, CCS-P, RHIT, RHIA, CDIP, CHDA, CHPS

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Key Takeaways

  • Comprehensive Understanding of MDM: Participants will develop a thorough comprehension of Medical Decision Making (MDM) and its pivotal role in the evaluation and management (E/M) coding process.
  • Subcomponent Mastery: Coders will become adept at assessing and applying the three critical MDM subcomponents: the assessment of presenting problems, complexity of data review, and the level of risk. They will learn how these elements contribute to the overall MDM level.
  • Documentation Evaluation: Participants will gain the skills to assess medical documentation accurately, identifying the essential information required to assign MDM components to E/M codes.
  • Risk Assessment: Coders will learn how to evaluate risk related to disease processes, diagnostic procedures, and management options, ensuring a precise determination of MDM.
  • Debunking Common Misconceptions: Participants will debunk common misconceptions, such as the belief that a single diagnosis, surgery decision, or prescription can independently determine MDM. They will understand that MDM involves a combination of subcomponents.
  • Organizational Impact: The course will highlight the organizational impact of MDM, emphasizing its significance in reflecting patient severity and provider judgment, ultimately leading to more accurate coding and improved healthcare delivery.

Benefits of Taking this Course

  • Expertise in Documenting MDM
  • Career Advancement
  • Increased Documentation Proficiency
  • Enhanced Coding Accuracy

FAQs

What is Medical Decision Making (MDM) in E/M coding?
Medical Decision Making (MDM) is one of the three key components in evaluation and management (E/M) coding. It involves assessing the complexity of clinical decisions made by healthcare providers when managing a patient's care. MDM is determined based on three subcomponents: the number and type of presenting problems, the amount and complexity of data reviewed, and the level of risk involved.
What is the significance of MDM in E/M coding?

MDM is crucial in E/M coding because it reflects the patient's condition's severity and the provider's clinical judgment. Accurate MDM coding ensures that the level of service is appropriately documented and reimbursed, reflecting the complexity of care provided.

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams. 

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Overview
Price
Price : $35.99
Courses
Courses : 1
CEUs
AHIMA CEUs : 1
CEUs
AAPC CEUs : 1
Code Type
CPT CodingE&M