Mastering Medical Decision Making

Duration: 90 Minutes
Instructor: Jeffrey Restuccio
Webinar Id: 800500


One Attendee


This in-depth, 90-minute Webinar will cover the fundamentals of Evaluation and Management coding and documentation and provide an in-depth analysis of the Medical Decision Making (MDM) Process and its impact on the level of E & M service.

Using specific clinical examples of Glaucoma, ARMD, Cataracts and an Injury the course will guide the participants through the different levels of MDM (Straightforward, Low complexity, Moderate complexity and High complexity), the specific documentation requirements and how they relate to the different levels of E & M (99213, 99214 and 99215) In this 90 Minute Webinar you will Learn. Specific clinical examples, combined with detailed and accurate documentation will ensure the level of service matches the documentation reported.

This presentation will include an overview of coding Evaluation and Management encounters and how to properly document the History, Exam and Medical Decision Making.

Why should you attend: One of the most misunderstood aspects of documentation and E & M code level is Medical Decision Making (MDM). Very few coders receive instruction in the MDM scoring system using by many government and independent auditors. Even few providers are aware that these guidelines even exist. MDM is the number one reason for Downcoding encounters. In addition, very few EMR help score MDM and most allow an easy upcode that could result in refunds and fines during an audit.

Areas Covered in the Session:

  • Fundamentals of an Evaluation and Management Encounter.
  • Overview of the Medical Decision Making process and documentation Requirements
  • The Marshfield Clinic Medical Decision Making Point system as adopted by Medicare Carriers and the OIG.
  • Apply the concepts learned to working case studies
  • Why 99.9 percent of EMR software packages will upcode your encounter.
  • The importance of Medical Decision Making in 2010 due to Medicare's dis-allowance of the E & M Consultation Codes.
  • Specific documentation elements needed to quantify the level of MDM.
  • How to explain the MDM process without scaring the doctors with the complexity of the Point System.
  • Strategies on how to implement proper MDM documentation and coding in your clinic.
  • Internet and additional Resources Jeff will provide a thorough review of this process, using real-life examples.

Who Will Benefit:
  • Coders
  • Coding Manager
  • Coding Auditors
  • Compliance Director
  • Providers

Speaker Profile
Jeffrey Restuccio is the principal owner of, a healthcare consulting company specializing in online training, live seminars, webinars, chart audits, and specialty consulting. Jeff is certified as both a CPC and a CPC-H from the Academy of Professional Coders (AAPC).

Jeff is an experienced educator and conducts training courses on CPT and ICD-9 coding and billing, auditing and compliance and has taught hundreds of live coding and billing seminars nationwide. He has audited over 10,000 medical records

Jeff teaches specialty seminars on topic such as carrier-specific rules, medical decision making, auditing, compliance plans and winning appeals. His clients include Hospital Corporation of America, Hospital Management Association, St Jude Children's hospital, the VA, DOD. and hundreds of small practices.

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