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

Video Transcription

Video Summary

In this video, the speaker provides an overview of the office E&M (Evaluation and Management) guidelines for 2021. They discuss the importance of understanding these guidelines and feeling confident in implementing them. The speaker highlights the three components of medical decision making: number and complexity of problems addressed, amount and complexity of data reviewed and analyzed, and the overall risk. They explain that the guidelines now emphasize decision making or total time as the basis for determining the level of service. The speaker also discusses the changes that were made specifically to the 99201-99205 and 99211-99215 CPT codes. They emphasize the need for documentation that clearly reflects the patient's chief complaint, history, examination, and plan of care. Additionally, the speaker explains how to determine the level of risk and provides examples of factors that contribute to each risk level. They also discuss time billing and offer documentation tips to ensure accurate and comprehensive records. The speaker encourages providers to clearly document the reasons for ordering tests, medications, or procedures, as well as any patient instructions or recommendations. They emphasize the importance of medical necessity in documenting the level of care and supporting pre-authorization of tests and procedures.

Asset Subtitle

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

Keywords

office E&M guidelines

2021

medical decision making

CPT codes

documentation tips

medical necessity