AUDITS: Look For Signs Of MDM Thought Process

Why This Topic Matters

Medical decision-making is a major factor in supporting E/M level selection, and incomplete documentation can put claims at risk during audit review. Understanding how to spot documentation that reflects clinical reasoning helps reviewers assess whether the record supports the reported service.

Article Sections

1. 7 tips to boost your E/M levels and improve documentation

   Introduces practical documentation topics related to evaluation and management services and audit review. The section frames the article around improving support for medical decision-making in the record.

2. Seven documentation tips for supporting MDM

   Presents several broad documentation themes tied to medical decision-making, including complexity factors, tests and medications, narrative detail, medical necessity, and clarification of sparse charting. The guidance is framed for auditors and coders reviewing E/M documentation.