decisionhealth Newsletters, Coder Pink Sheets - 2026 Issue 6 (June)
Boost communication to augment E/M medical decision-making
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Article Overview
This article discusses practical documentation guidance for E/M medical decision-making (MDM), with emphasis on improving communication between coders, auditors, and providers. It is aimed at professionals involved in E/M review, documentation improvement, and auditing, and it focuses on broad concepts such as shared MDM, role-related responsibility, separately reported services, and strengthening documentation support.
Why This Topic Matters
Accurate E/M documentation affects whether the medical record supports the level of service selected. The article is relevant for teams trying to improve provider education, clarify communication around MDM, and reduce documentation gaps that can affect compliance and audit outcomes.
What You Will Learn
- How communication can help clarify support for E/M medical decision-making
- General considerations for documenting shared medical decision-making
- How separately reported services relate to MDM documentation review
- Ways to frame documentation feedback for future provider improvement
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physician educators
- Billing staff
- Compliance professionals
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