2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing | November 2021-Understanding E&M 2021 Revisions: Part 2: Risk of Complications/Morbidity or Mortality of Patient Management with Clinical Examples

Understanding E&M 2021 Revisions: Part 2: Risk of Complications/Morbidity or Mortality of Patient Management with Clinical Examples

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Video Transcription

Video Summary

In this video, the speaker discusses the third column of medical decision-making called risk. They provide examples of different levels of risk, such as minimal risk, low risk, moderate risk, and high risk. They emphasize the importance of accurately documenting risk factors for procedures, particularly for endoscopic procedures. The speaker also addresses common questions, including the definition of a chronic stable condition, the criteria for intensive monitoring for toxicity, and the requirement for the review of systems section in documentation. They stress the need for providers to specify specific tests for monitoring toxicity and clarify that although the review of systems section is not a requirement, relevant symptoms should still be documented in the history section. The speaker concludes by reminding providers that they are responsible for all information entered in the note and should ensure accurate and complete documentation before signing the record. No credits were mentioned in the video.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

medical decision-making

risk

endoscopic procedures

toxicity

documentation

note signing