Chief Medical Information Officer St. Joseph Health System Hoboken, New Jersey
Disclosure(s): No financial relationships to disclose
As the rules of healthcare change it is important for physicians to understand how our documentation will be judged by others, both by payers and our peers. The AMA guidelines have shifted towards a heavy emphasis on a descriptive MDM section of our charts. It is important to understand the components and verbiage required to emphasize the body of work preformed. During this session we will go over key differences for improved documentation, and examples to show how to craft the MDM section note to cover both complexity and risk while being efficient written. New tools are emerging in the documentation space such as computer assisted coding and artificial intelligence we will discuss how these technologies will play a role in the documentation and reimbursement.
Learning Objectives:
Create a concise and effective MDM section of their note to describe their interaction with their patient.
describe various components of the table of risk used to determine the level of the E/M code assigned to the patient encounter.
Explain how AI technologies are being used in coding today.
create a concise and effective MDM section of their note to describe their interaction with their patient.