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.
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.
- Caral Edelberg
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...
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