PHYSICIANS: To Avoid Audits, Show MDM Thought Process

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains why medical decision-making documentation is often the focus of audit review and offers general documentation guidance for physicians and coding staff. It discusses broad ways to better support evaluation and management services by capturing complicating factors, test and medication details, and the reasoning behind treatment choices. The piece is aimed at physicians, coders, auditors, and compliance professionals who want to understand what makes E/M documentation more defensible.

Why This Topic Matters

Clear medical decision-making documentation can affect how well claims withstand audit scrutiny and whether the chart reflects the clinical work performed. Understanding the documentation themes covered here can help practices improve compliance and support E/M service levels.

What You Will Learn

  • Why medical decision-making documentation is a key audit focus
  • What kinds of clinical details can strengthen documentation
  • How documentation style can affect higher-level evaluation and management visits
  • Why the reasoning behind treatment choices matters in the chart

Who Should Read This

  • Physicians
  • Medical coders
  • Auditors
  • Compliance staff
  • Practice managers

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