2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-Overview of E&M Documentation Guidelines

Video Transcription

Video Summary

The video is an overview of the office E&M guidelines for 2021. The speaker discusses the changes in the guidelines and emphasizes the need for providers to understand and follow them. They mention that the guidelines now focus on medical decision making or total time to determine the level of service. They go into detail about the three components of medical decision making: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the overall risk to the patient. The speaker explains that documentation should be clear and specific, and they provide examples of how to appropriately document history, examination, and assessment and plan. They also mention the importance of documenting social determinants of health and risk factors. The speaker concludes by discussing time billing and documentation tips to support medical necessity. No credits are granted in the video.

Asset Subtitle

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

Keywords

office E&M guidelines

2021

medical decision making

total time

documentation

social determinants of health