Identifying Emergency Department Medical Decision Making (MDM) Components and Risk Factors

Event Information
Product Format
Prerecorded Event
Presenter(s)
Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC
Conference Date
Thu, Jul 28, 2016
Length
60 minutes
Product Description

Documenting MDM in Detail to Support Medical Necessity and to Prevent “Upcoding”

 

The ability to identify elements of medical decision making (MDM) and medical necessity are the foundation of emergency medicine coding. Understanding these elements also provides valuable information on how well or how poorly other critical elements of a medical chart are documented.

This session by expert speaker Caral Edelberg will dissect the medical decision making components of a medical record and present thoughtful insights to assist coding professionals and providers in understanding how risk factors, interventions, and diagnosis define levels of medical decision making. Caral will investigate real medical records, from basics to complex, to present methods of discovery of the components of risk and other elements of MDM.

Electronic medical records often record minute-by-minute information of the emergency department patient encounter.  The critical information that impacts medical decision making and medical necessity must often be entered in a narrative format to capture the elements that illustrate the condition of the patient and the need for additional studies.  This session will also provide a deep dive into how medical decision making should be documented to support medical necessity and prevent upcoding.

Session Highlights:

  • What is Medical Decision Making?
  • What is medical necessity and how does it apply to ED Medical Decision Making?
  • Establishing medical necessity through MDM
  • Do providers understand documentation requirements for the services they perform and/or order?
  • How do payer look to MDM to determine medical necessity?
  • Best practice collaboration between coding professionals and providers to improve documentation and reduce risk
  • Review typical “down codes” on emergency department charts
  • Methods to track and improve charting of MDM and avoid audits
  • Case studies and discussions

Session Snapshots:

  • Documentation – Your First Defense
  • Physician orders for diagnostic study vs. protocol orders
  • Emergency Medicine Hot Spots
  • Number of Diagnosis and/or Management Options
  • Risk Table
  • 1995 Documentation Guidelines

Who should attend?

Coding professionals, auditors, compliance experts, emergency physicians, emergency nurses, practice managers

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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Phone

1-866-458-2965

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1-919-287-2643

About Our Speaker

Caral Edelberg - Emergency Medicine Coding Expert

Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, leads the overall growth and operational delivery of Edelberg + Associates’ in coding, compliance and education. Caral is a well-regarded author, lecturer and industry expert in healthcare revenue cycle management, coding and compliance. Caral maintains a long list of certifications and affiliations which include: dual coding certifications from the American Health Information Management Association (AHIMA) and the American Academy of Professional...   More Info
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