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

Pdf Summary

The presentation discussed the 2021 Office E&M Guidelines. The changes included the deletion of 99201 and new guidelines specific to 99202-99215 codes. There were also changes in component scoring for both new and established patient codes, as well as changes to the medical decision-making table and the typical times associated with each E/M code. Time billing for E&M services was also introduced as a new option.<br /><br />The guidelines emphasized that the level of decision making would be based on decision making or total time, rather than history and physical examination. The table of risk was discussed, which includes the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.<br /><br />The guidelines also discussed the number and complexity of problems addressed, which determines the level of E/M services. The amount and/or complexity of data reviewed and the risk of complications or morbidity were also important factors in determining the level of service.<br /><br />Time billing was introduced as an option for E&M reporting in 2021. Clinicians can count the time they spend performing various activities on the day of the patient's visit, including face-to-face and non-face-to-face time.<br /><br />Documentation tips were also provided, emphasizing the importance of including all pertinent information in the history of present illness, impression, and plan sections. The history and examination should still be relevant to the patient's chief complaint, even though they don't directly factor into the level of visit in the office setting.<br /><br />Overall, the presentation aimed to provide an overview of the changes and considerations for coding E&M services in 2021.

Asset Subtitle

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

Keywords

2021 Office E&M Guidelines

99201 deletion

99202-99215 codes

Component scoring

Medical decision-making table

Time billing

Table of risk

Level of service

Documentation tips

Coding E&M services