decisionhealth Newsletters, Coder Pink Sheets - 2019 Issue 10 (October)
Work on your MDM, seize time-based opportunity under revised E/M rules
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Article Overview
This article discusses how revised E/M documentation rules affect medical decision-making and time-based reporting. It is aimed at clinicians, coders, auditors, and practice staff who need to understand documentation expectations, time tracking, and template updates under the newer framework. The piece focuses on broad guidance for documenting work performed, capturing time, and preparing for audit scrutiny.
Why This Topic Matters
Changes to E/M documentation can affect how encounters are supported in the record, how time is captured, and how practices train staff and update workflows. Understanding these shifts helps organizations reduce audit risk and adapt documentation processes.
What You Will Learn
- How revised E/M documentation rules change the emphasis on documentation elements
- Why medical decision-making documentation becomes more important
- How total time concepts affect encounter documentation
- Which practice workflows may need review when time is documented
- Why audit readiness matters for E/M records
Who Should Read This
- Physicians
- Advanced practice providers
- Medical coders
- Auditors
- Practice managers
- Clinical documentation staff
Codes Discussed
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