2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing (On-Demand) | November 2021-03 - E&M 2021 Rev Pt 2 - Risks and Patient Management

03 - E&M 2021 Rev Pt 2 - Risks and Patient Management - Vaughn

Pdf Summary

The document titled "Understanding E&M Revisions Part 2: Risks of Complications/Morbidity of Patient Management" discusses the changes in the 2021 E&M Risk Table and provides examples of medical decision making (MDM) risks. It also covers the risks associated with endoscopy procedures. The document explains that one element used in selecting the level of service is the risk of complications and/or morbidity or mortality of patient management at an encounter. The risk is distinct from the risk of the condition itself. The level of risk is based on the consequences of the problem(s) addressed at the encounter when appropriately treated.<br /><br />The document provides examples of risk levels based on the 2021 MDM Table. For example, minimal risk is associated with no clinical examples provided, low risk includes OTC medication and minor surgeries without risk factors, moderate risk involves prescription drug management and minor surgeries with identified risk factors, and high risk includes drug therapy requiring intensive monitoring for toxicity and major surgeries with identified risk factors.<br /><br />The document also explains the risks associated with endoscopy procedures. It states that endoscopy procedures can be considered either minor or major surgeries, depending on the provider's statement and any risks to the patient. Several examples are provided, including a patient scheduled for an upper GI endoscopy with overall low MDM risk, a patient with underlying conditions scheduled for a lower endoscopy with moderate MDM risk, and a patient with pancreatic cancer requiring an emergent ERCP for stent placement with high MDM risk.<br /><br />The document concludes with some tips and questions related to medical decision making. It clarifies the definition of an external physician/qualified health care professional, the definition of a chronic, stable condition, and what is considered intensive monitoring for toxicity. It also discusses the need for clarification regarding the review of systems (ROS) requirement under the new documentation guidelines, stating that although ROS is not a requirement, pertinent information should still be documented based on the patient's symptoms.

Keywords

E&M Revisions

2021 E&M Risk Table

Medical Decision Making

MDM Risks

Endoscopy Procedures

Risk of Complications

Morbidity of Patient Management

Risk Levels

Minor Surgeries

Major Surgeries