Every day, providers make complex medical decisions, but documentation often fails to fully reflect that complexity. Most clinicians receive little to no structured education on E/M coding, documentation requirements, or MDM criteria during medical training and despite significant time spent on patient care, medical decision making (MDM) notes frequently lack the detail needed for coders and auditors to assign the correct E/M level. The result? Under‑coding, compliance exposure, and lost revenue due to documentation that doesn’t tell the full story of the provider’s work.

In this essential webcast, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the latest MDM documentation requirements and translates them into practical, real‑world language that makes sense for providers. Through real patient scenarios and clear examples, Stacey will show how to document complexity confidently and efficiently, without adding to charting time.

Why This is Relevant:

Now more than ever, accurate MDM documentation is critical. With multiple guideline changes since 2021 and increasing scrutiny from payers and auditors, providers can’t afford to let unclear or incomplete notes undermine coding accuracy. This session delivers actionable guidance that helps clinicians protect compliance, demonstrate clinical reasoning, and ensure their documentation matches the care they deliver.

Learning Objectives:

After attending, you’ll be able to:

• Understand the core components of Medical Decision Making (MDM) and how each element (problems, data, and risk) impacts visit level selection.
• Identify common documentation gaps that prevent providers from receiving appropriate credit for the complexity of care delivered.
• Apply practical strategies to improve clarity and completeness of MDM documentation, ensuring it accurately reflects clinical thought processes.
• Distinguish between different MDM levels using real‑world scenarios, enabling providers to confidently document and support the correct E/M level.
• Optimize provider workflow by integrating efficient documentation habits that enhance coding accuracy without increasing charting burden.

Who Should Attend:

MD, PA, NP