Welcome to our Back to Basics blog series — a refreshing guide designed for both new and seasoned healthcare professionals to revisit core clinical concepts. Whether you’re a newly credentialed clinician stepping into your first role this fall or a seasoned provider looking to revisit foundational best practices, this series was created with you in mind. Coders, auditors, compliance professionals, and care team members—you’re invited too.
Why This Matters
As the clinical year begins, now is the perfect time to pause and realign. In the fast-moving world of healthcare, it’s easy to overlook the foundational elements that support accurate coding, quality care, and defensible documentation. Medical Decision Making (MDM) sits at the center of many of these requirements, yet it’s often misunderstood—or inconsistently applied.
This series will walk through the core components of documentation, with a focus on clarity, compliance, and clinical relevance. Each post is short, practical, and built for busy professionals.
What to Expect – Series Schedule
We’ll begin with a breakdown of MDM and then move into other essential documentation areas like the Review of Systems, Physical Exam, timely authentication, and even the often-misused 99211 code.
Here’s what’s coming:
- August 14 – MDM Element: Undiagnosed New Problem
- August 19 – MDM Element: Self-Limited Problems & Stable Chronic Illnesses
- August 21 – MDM Element: Acute Complicated Injury – How It Differs from Acute Uncomplicated
- August 26 – MDM Element: Data – Labs, Imaging, and External Records
- August 28 – MDM Element: Risk – Risk of Complications and/or Morbidity or Mortality of Patient Management
- September 2 – ROS & PE: Avoiding Common Pitfalls
- September 4 – Timely Authentication & FTCA Compliance
- September 9 – 99211: The Misunderstood Code
Each post will offer examples, quick tips, and actionable insights for improving documentation at the point of care.
Who Should Follow Along?
Maybe you’re a new clinician getting your feet under you.
Maybe you’re returning from a well-earned summer break, ready to reset your workflows.
Maybe you’re a coding or compliance professional preparing for audit season.
Or maybe you’re simply someone who values doing things right from the ground up.
No matter your role—you’re welcome here.
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