Unveiling Effective Documentation for the Medical Decision-Making (MDM) Table


CEU: 1

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Title: Unveiling Effective Documentation for the Medical Decision-Making (MDM) Table


Presenter: Betty A. Hovey, BSHAM, CPC, COC, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Senior Consultant and Owner of Compliant Health Care Solutions


Time: 1.00 hour




Betty A. Hovey from Compliant Health Care Solutions discusses effective documentation for Medical Decision-Making (MDM). Understanding CPT E/M definitions and current guidelines of the MDM table is imperative to improve compliance and specific documentation areas.




  • Identify the importance of documentation in relation to the MDM table
  • Acknowledge when documentation improvement is necessary in the medical record to support the E/M service chosen.
  •  Implement best practices for documenting using the MDM table.


Key Topics:


  • Coding by MDM
    •  Guidelines for Element 1
    •  Guidelines for Element 2
    •  Guidelines for Element 3
  • Coding by MDM
    •  Double-Dipping
    •  MDM Table for E/M Service
  • Shift in Methodology
    •  Effective Documentation
    •  Understanding MDM
    •  Education
    •  Leveraging Technology
    •  Regular Audits
  • Pain Points
    •  Chronic Conditions
    •  Example
    •  Self-Limited vs Acute, Uncomplicated
    •  Data
    •  Data: To Count or Not to Count?
  • •  Final Points


Compliant Health Care Solutions


Betty is a nationally recognized health care consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable. Betty's philosophy is, "Physicians work hard for their patients and they should be paid properly for what they do."


Betty brings over thirty years of healthcare experience. She has worked for practices both large and small with the same intensity and attention. She has spent years on the "front lines" for practices handling medical billing, coding, claims, and denials.  She has also managed practices and directed health care system departments. Her areas of specialization include Evaluation and Management, Primary Care, Dermatology, Plastic Surgery, Cardiology, Cardiothoracic Surgery, General Surgery, GI, E/M and procedural auditing, and ICD-10-CM.


Compliant Health Care Solutions is a consulting firm that provides compliant solutions to issues for all types of health care entities: solo practices, physician groups, physician offices, health care systems, care facilities, and payors.