Mastering Medical Decision Making

Duration: 90 Minutes
Instructor: Jeffrey Restuccio
Webinar Id: 800151


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

Educational Objectives(S)
Upon completion of this activity, participants will be able to:
  • Discuss the fundamentals of evaluation and management coding and documentation.

CME Credit Statement
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Colorado Foundation for Medical Care (CFMC) and MentorHealth. CFMC is accredited by the ACCME to provide continuing medical education for physicians.

Colorado Foundation for Medical Care designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Other Healthcare Professionals Credit Statement
This educational activity has been planned and implemented following the administrative and educational design criteria required for certification of health care professions continuing education credits. Registrants attending this activity may submit their certificate along with a copy of the course content to their professional organizations or state licensing agencies for recognition for 1.5 hours.

Disclosure Statement
It is the policy of Colorado Foundation for Medical Care (CFMC) and MentorHealth that the faculty discloses real or apparent conflicts of interest relating to the topics of the educational activity. All members of the faculty and planning team have nothing to disclose nor do they have any vested interests or affiliations.

Obtaining Certificate of Credit

Colorado Foundation for Medical Care (CFMC) hosts an online activity evaluation system, certificate and outcomes measurement process. Following the activity, you must link to CFMC’s online site (link below) to complete the evaluation form in order to receive your certificate of credit. Once the evaluation form is complete and submitted, you will be automatically sent a copy of your certificate via email. Please note, participants must attend the entire activity to receive all types of credit. Continuing Education evaluation and request for certificates will be accepted up to 60 days post activity date. CFMC will keep a record of attendance on file for 6 years.

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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