BC Advantage - 2018 Issue 5
The Devil is in the Data Details
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Article Overview
This article explains the data portion of Medical Decision Making (MDM) as it relates to E/M audit review. It is aimed at coders, auditors, and documentation specialists who want a clearer understanding of how encounter documentation supports MDM assessment, with attention to broad data categories, record review, and provider-to-provider information exchange.
Why This Topic Matters
Accurate documentation of the data component can affect how E/M services are supported during audit review and how the complexity of medical decision making is interpreted from the record.
Article Sections
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Medical Decision Making and data complexity
Introduces the MDM framework and the role of data in determining overall complexity for E/M services. It summarizes the broad elements used in the article’s audit discussion.
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Point system for data elements
Outlines the general categories of data activity considered in the encounter record and how they are grouped for review purposes. The section focuses on the structure of the data component rather than specific code selection.
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Clarifying common documentation issues
Discusses several documentation concepts that are often misunderstood or underdocumented in audits. It covers broad distinctions among types of record review, history gathering, inter-provider discussion, and independent image review.
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Audit implications for provider documentation
Explains why complete documentation of data-related activities can matter in evaluating encounter complexity. The section frames the topic in terms of audit readiness and documentation quality.
What You Will Learn
- How the data component fits into the broader MDM framework
- What general categories of activities contribute to data review in E/M documentation
- Why documentation detail matters during audit review
- How data-related documentation practices can influence assessment of encounter complexity
Who Should Read This
- Medical coders
- Clinical auditors
- Compliance staff
- Documentation specialists
- Physicians and other healthcare providers
Code Ranges Discussed
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