Moderate MDM — Is It Clear in the Medical Record?

If you spend your days auditing charts, you’ve seen it: diagnoses are listed, medications are “continued as prescribed,” and a plan is documented — yet something important is missing.

In this episode of CodeCast, Terry explains how small documentation improvements can make medical decision making (MDM) clearer and more defensible. Learn how generic or repetitive macro phrases can unintentionally invite payer scrutiny, and what clinicians can do to better reflect the true complexity of the encounter.

With payers increasingly using AI tools to review and downcode E/M services, clear documentation is more critical than ever. Every note should answer the essential question: Why is the patient here today?

Tune in for practical tips to strengthen your documentation and reduce audit risk.

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