Thank you, Kathy, for the updates. Again, not too many changes, but I kind of, I'm one of those that I don't like a bunch of change at one time. So hopefully you guys can take that information, apply that to your practice, make sure you got, you know, all of your ICD DIN codes uploaded, things like that. So now we're going to kind of get into a discussion on the evaluation and management services. All right, so as most of you probably are aware, we did have a drastic change in 2021 for the office side, and then again in 2023 for the hospital observation side. So we're going to kind of talk about all of that. So again, we're going to go through the changes. I'm not going to go through all of the fine comb details that CPT has in place for the new guidelines. It kind of did an overhaul of the guidelines and the parenthetical advice. We would be here all day, but I'm going to point out the main points, the ones that are going to impact your documentation, your levels of services, and talk definitely about medical decision-making. You know, Kathy had just said that your assessment and plan of care is the most important part of your note, and it is. You know, your chief complaint should flow into your HPI. Your HPI then should flow into that assessment and plan, and a lot of times when we do reviews, we see disconnects. So we see, you know, you've got two or three things that you address up in the HPI and then no mention of them in the assessment and plan and vice versa. So we're going to talk about that. So breaking down that decision-making between complexity of problems addressed, data, and risk, and the definition of those things, what they mean, what gets counted, what doesn't get counted, what you need to have as a provider in your documentation to make sure your level of risk is supported. We are going to talk about time billing, and again, what can count, what doesn't count, and I know Kathy kind of went over that as well. And then documentation tips just in a whole. All right, so 2023 E&M Guidelines, you can find this information on the AMA, all right? We can all Google it and find it, but there are the guidelines that they had published January 1st to kind of give you that guidance on what has changed for specifically the hospital and observation side of things and your consultations. So we do still have practices out there that bill for consultations, but one of the big things is we have to make sure that we're still meeting the documentation criteria to support consultations, again, to support your inpatient, your observation services. So they made updates and guidelines revised specifically to your 99221 through 223, that's your initial inpatient or observation, your follow-ups and your discharge, again, inpatient or observation, consultations again, and one big thing that we point out, and it's here in red, is deletion of observation services, all right? So if you're still trying to bill for observation services, you're most likely not getting paid for those or they're denied because we don't, those are not in effect anymore, all right? Now, in GI, we really don't have to typically deal with these too much because we're typically not the admitting provider, but you could definitely come across scenarios and there are definitely GI practices, gastroenterologists out there that do have admitting privileges. All right, so they deleted the observation codes, they revised the inpatient and observation care code, so what that means is if you look to the 99221 through 223, your hospital follow-up 231 through 233, and your discharge services, when you look into the description, they no longer just say inpatient, they say inpatient and observation, all right? So keep that in mind. So it doesn't matter whether your patient is sitting in a hospital bed, whether they're inpatient or observation, you're going to report the same CPT code for either one. What we bill out that determines and lets the payer know that it's an inpatient versus observation is the place of service that is going out on that claim, all right? So I could bill a 99222 in either place of service 21, if the patient is technically inpatient, or I could bill that same code, 99222, place of service 22, okay? That's how it works. So they've just combined them all. They deleted your level one consultation, so level one consultation for the office, and then level one consultation for the inpatient side of things, all right? So if you're trying to bill those out, you're not going to get paid for them. I hope all of you GI providers listening in have never billed a level one. You guys are consultants. If you have, I'm sure it was on accident. A level one is a straightforward, I'm not sure what you're doing here type of visit. All right, so that's kind of why they deleted them. They were underutilized. So revision of consultations, again, they've updated the guidelines on all levels of services, two through five for outpatient consults and two through five for inpatient consultations. So a couple of pointers. Again, I didn't pull all the changes and guidelines and definitions that CPT now has. I pulled the important pieces or the important tips and topics. So the first one, the place of service and service types are defined by the location where the face-to-face encounter with the patient and or family caregiver occurs. For example, service provided to a nursing facility resident brought to the office is reported with an office or other outpatient code, okay? Okay, so it's basically it's where the patient ends up. For reporting hospital inpatient or observation care services, a stay that includes a transition from observation to inpatient is one stay, okay? So note that. Here's the thing. We should not hold providers responsible for knowing exactly what place of service their patient is the day they see them. We have seen many cases where a patient could be in the hospital for two weeks and start observation, then flip back to inpatient, then back to observation and back to inpatient. It all has to do with payer requirements. So payers specifically have guidelines set forth as to where these certain criteria, this patient has to meet these certain criteria to be an inpatient. Otherwise, they're sitting in observation, okay? Medicare, of course, has the two midnight rule. So there's just there's variances. So again, when providers go see patients in the hospital, just because they are going over to the hospital does not mean place of service 21 all the time, okay? So your responsibility as a provider is to obviously see the patient, document your encounter and bring back your level of service and the date you saw that patient, okay? So billing is going to determine, they're going to get the last most recent face sheet from the hospital and determine is that patient observation or inpatient. All right, so some of the guidelines for your visits, okay? So again, as Kathy mentioned, we're kind of all on the same page now for E&M guidelines. So these should be easier to follow because we don't have to wear two hats anymore. So remember, when they updated the office guidelines in 2021, we had office guidelines to follow. We still had to wear our old 95, 97 E&M guidelines when we went over to the hospital. And it was a very, it caused a lot of confusion. So now they've made this guideline the same for any level of visit you submit, wherever you see the patient, it doesn't matter. We're all kind of under the same umbrella as far as history, exam and decision-making goes. So for history and exam, E&M codes that have levels of services including medically appropriate history and or physical exam when performed, okay? The nature and extent of the history and or physical exam are determined by you, the reporting provider, providing the service. The care team may collect information and the patient or caregiver may supply information directly, whether it's through portal, questionnaire, your review of system sheet, whatever it is, that is reviewed by you, okay? You ultimately have to review any information that is put into your note. You need to review it to make sure it's correct. The extent of history and physical is not an element in selecting your level of service. So if you're billing out a level four follow-up in the office, you're not being counting your history and exam elements. And I'm gonna tell you, I've been into a couple of practices recently where they still had the old guidelines turned on. And so all their visits were, they were all over the place, let's just say. So make sure that we're aware, we are not selecting levels by history and exam. Your level comes from decision-making or like Kathy had mentioned, total time performed on the date of the encounter. Okay, those are your two options. Now, I'm gonna say this and I'm probably gonna mention it again. Make sure you document some sort of history and exam. I'm seeing visits now that have none of it documented. No chief complaint, HPI is one word. So you gotta make sure it's relative to the chief complaint. All right, question. How many review of systems have to be documented for a level four new patient visit? 10 or more? Those that are pertinent to the chief complaint? None? I can't even pretend to know. All right, so I'm gonna go ahead so 48% of you are correct. Those that are pertinent to the chief complaint. All right, so remember, we no longer are required to put 10 or two or five just as long as they're pertinent to the chief complaint. And that's kind of one of those things that I see still again is that we still have the same templates that we had from the old guidelines. We don't need all that information. And is it wrong to put it in there? Not necessarily, not saying that. But when we have more information in our note than we even need, that puts us at risk for contradictory information. And for if the patient mentions all these positive elements that you're not seeing them for, it doesn't look good. It's like, oh, I have edema and I have shortness of breath and I have altered mental status and we don't address any of those things. So it doesn't look good. So again, I only recommend you definitely have to document a chief complaint. Has to be there on every note. It establishes why you're seeing the patient. A pertinent history, a pertinent exam, your assessment and plan is key. All right, so we're going to go through, if you look into your CPT book, which you should all have a copy of the 2024 CPT book and hopefully soon if you don't now, but you'll see this in 2023 as well in your 2023 CPT book. These are the guidelines or the definitions of all of the levels of services that you're billing out. So your 99221 through 223, again, you're going to see initial hospital inpatient or observation care per day, okay? And again, they all say, which requires a medically appropriate history and or exam and straightforward or low decision-making or 40 minutes for a one, moderate decision-making or 55 minutes for a two, high-level decision-making or 75 minutes for a level three. Okay, so those are your initial hospital inpatient or observation care services. So GI, we do report these services, okay? Because we have a lot of payers, Medicare in particular, they don't accept consults, they haven't for a long time, all right? So when we see a patient initially in the hospital, we bill 99221, 222 or 223. Here's your subsequent hospital or observation care codes. Again, three levels, medically appropriate history or exam. You've got a level one for low decision-making or 25 minutes. You've got moderate decision-making or 35 minutes. And then a level three is your high-level decision-making 50 or 50 minutes, okay? So those are your different levels of services. Consultations. Again, we do still have payers that do accept consultations. So inpatient or observation, it doesn't matter. If the payer accepts a consult, you perform a consultation, you document it appropriately, then your level is based upon decision-making or time. All right, so I'm not gonna read every single one of these to you. They're here for you to have quick reference. Again, they deleted the level one. Here's your office or outpatient consultations. So again, you're seeing the patient in the office and you still have payers that allow for consultation services. These are what you are going to be reporting, level two, three, four or five. And again, based upon decision-making or time. All right, so, and I know Kathy had mentioned time documentation and we always recommend, don't build by time unless your decision-making doesn't support the level. Specifically, when you're talking about new patients or your initial visits or consultations, I mean, that's a lot of time that you have to have to spend. So 99254, for example, in the hospital, that's 60 minutes, it's an hour, all right? So just be aware of that. Look at your time thresholds for your levels and then determine, is it worth documenting and billing by time or is it not? And I've got some examples on my next talk. ER services, levels one through five. These are not time-driven, okay? These are only decision-making. And then these are from the 2021 guidelines. So you guys should be very, very, very, very, very familiar with the requirements for your new patients in the office and your follow-up patients in the office. Medically appropriate history and or examination. But again, you're looking at your assessment and plan, data, anything involved like that. And you're determining, okay, did this meet straightforward, low, moderate or high decision-making? Or if I'm billing by time, you have to meet the time threshold within that CPT code description. And here's your follow-ups, 99212, 213, 214, 215. Same thing, decision-making or time. All right, so let's break down medical decision-making, okay? What are we talking about here? Well, and this table might look a little daunting, but it's a good tool for you to follow, especially if you've got, depending upon your medical record, you may not have something that's right next to you where you can kind of use it as a guide to determine what level of service you're billing out. So this is kind of a description of, on the far left are all your levels of services, okay? Whether the patient's new patient in the office, follow-up, inpatient, consultation, ER, it doesn't matter, they're all there. So straightforward, low, moderate or high, okay? So off to the right of that is problem addressed, data and risk. You need two of those three to meet your level of service, all right? So for example, if I have a moderate for problem addressed and a moderate risk, I'm gonna go down here to moderate, and let's say it's a new patient in the office, that is a 99204, that's how you determine it. So they really have tried to simplify figuring out our levels. Now we have to determine what meets straightforward, low, moderate or high. And again, guys, this is all in your assessment and plan of care. Now I know sometimes you'll do an external record review, you'll do data review, things like that. And some of that might be up in the HPI, that is okay. All right, we can still count it. It doesn't matter where it is in the note as far as data goes, but your problem addressed and your decision-making or what you're doing about it, that all needs to be in the assessment and plan. So straightforward for a problem addressed is self-limited minor issue. So basically you're looking at the patient like, why are you here today? Go home, take some tubs, all right? That's really a straight self-limited issue, okay? We don't see a lot of those. Sometimes we do, but majority of the time your problem addressed is gonna be low, moderate or high. So for low, you've got two self-limiteds, one stable chronic condition, an acute uncomplicated illness or injury, a stable acute illness or an acute uncomplicated requiring hospital or observation level of care, all right? So an example of a stable chronic patient comes in with reflux, they're doing well, you're continuing them on their PPI therapy, you make them a follow-up appointment in six months, that is one stable chronic condition, low, okay? Moderate, now you're getting into one chronic condition with exacerbations, two or more stable chronic conditions, an undiagnosed problem with uncertain prognosis, acute illness with systemic symptoms or an acute complicated injury, okay? So for this, the first bullet, Crohn's or ulcerative colitis and the patient is experiencing a kind of a flare that you're doing a workup on, that could be definitely moderate. Two stable chronic conditions, I have a patient that comes in, they have reflux and IBS, they're doing well with both, I renew their medication, send them on their way, that's moderate, two chronic conditions is moderate, okay? Undiagnosed problem with uncertain prognosis, We get a lot of these patients, your abnormal LFTs, your abnormal CT scans, things like that where, you know, primary care sees the patient for this issue, they don't know what's going on, or the labs come back, transaminases all out the skyrocketed, they send the patient to you and you do your own workup because you're not sure what it is. That's an undiagnosed problem, okay? High is going to be chronic condition with severe exacerbation, progression, or side effects of treatment, or something that poses a threat to life or bodily function, okay? So in those two examples, you're pretty well either going to send them over to the hospital or you're getting something done immediately, okay? So you've got a severely exacerbated patient, or again, threat to life or bodily function. Now my next presentation, I'm going to put all of this stuff into case studies so you have a little bit better understanding of maybe where your levels of service fall, okay? So don't expect you to memorize every little example that I just gave you because we have those for you in the next talk. Now I apologize, this is very small. It's the requirements for data, amount and complexity of data, all right? So there's a lot involved in data, okay? There's a couple of things that we got to break down is, well, first of all, minimal, low, moderate, or high is your choice, are your choices. We're talking about external record review, okay? When I say external record review, someone else's records, primary cares, cardiologists, the last hospitalization, that's external. What we mean is you can't pull up your last clinic note and count that as review data, review of data, okay? That's all just part of your decision making, your time, whatever, whichever one you are billing that day. All right, review of a unique test or ordering a unique test, okay? So a couple of things with the test is if you order it, that's when you get credit for it. When you review it the next day, the assumption is you're going to review that test, so you can't get credit for both. So you get the credit at the time of the order, unless for some reason the patient isn't face-to-face with you. So for example, patient calls, all right, makes their six-month appointment, nurse is going through their records and says, oh, you need your labs. Get your labs before you come see the doctor. Patient comes in, you review those labs with the patient. Now you get to count that as a review because you weren't, you didn't have a face-to-face with them to order them, okay? Those were ordered non-face-to-face, okay? So, but again, you order them one day, you review them the next day, and you see the patient both days, you only get credit for the order. A unique test is defined by a CPT code set, all right? So it's no longer, you know, back in the old days, the old guidelines, you could have ordered 80 labs and it was one point. We were on this point system. It's no longer. If you order a CBC, a hepatic panel, and a CT, those are three unique tests. So if you look at this chart, three unique tests, you're already down here at moderate. But you have to tell us that, okay? You have to tell it, give us that information. I ordered XYZ. I reviewed XYZ. If we don't know, we can't guess, we can't assume. We all know what that means, okay? Another component is independent historian, and we get a lot of questions. Well, what does that mean? Okay, independent historian means, let's say you're seeing a patient in the office, they bring their spouse with them because they're either, they've got some dementia, they've got poor compliance, or they just are a terrible historian, or they've got intellectual disabilities, things like that. And you have to get history from that other source that came to clinic with them. And that's all you need to document. You can put it in your HPI, wherever, you know, per patient spouse, patient is also experiencing XYZ. That's all you need, okay? That's independent historian. Another one, and this is a separate category, is independent interpretation of a test by another provider, okay? So you're not looking at a CT, the CT result. You are personally pulling up that CT and providing your opinion on it. So I personally interpreted the CT image, which showed XYZ, versus, again, looking at the result that the radiologist said, and they just said, oh, there's bile duct stones, okay? That's the difference. That would go more for a review of a test versus an independent interpretation. So you got to tell us, I personally reviewed, I personally interpreted. Another one, and this is category three, discussion of management or test interpretation with an external provider, okay? So that's not going to your colleague and talking to them about a lab result. This is calling the lab, the pathologist, or the cardiologist, or the hospitalist, and having a discussion with them regarding the management of the patient. And I know you guys do that a lot, especially in the hospital, all right? But you got to document it. So we don't need a dissertation in your note. We just need, you know, spoke with hospitalist, and he agrees that XYZ, okay? That meets the requirements, okay? So you have to meet certain components within the categories to determine what level you're at in the data aspect of things. Then you've got risk, okay? Risk is risk. And I'm going to tell you, before I start going into risk, the AMA specifically states it is up to the provider to determine the level of risk, okay? So if you think your patient is high risk for this procedure, say it, okay? If they're at high risk to be put on this medication because of their kidney issues, say it, okay? We have to, that lay terminology has to be there. So when you're trying to bill a level five, and the payer's like, no, I don't believe you, I'm going to request your records, which they often do on higher levels, and they read through your assessment and plan, and they can't figure out why you billed a five, they're going to pay you for a four, and they're going to tell you why, all right? So, but if you've got in your assessment and plan, patient is at high risk for developing this because of this, there you go. We can't argue that. Nobody can argue that, okay? So I can't stress enough, you define the risk as the provider. Now, the AMA does give us some examples, and that's kind of what we're going to go through, are some of the examples that they do provide. So straightforward. They give you no examples of minimal risk. They give you no examples of low risk. They do give you examples of moderate and high risk. So prescription drug management is on moderate. So think about that. How many patients do you have on prescriptions? That's pretty easy, isn't it? So what do we mean, though, by prescription drug management, okay? So most payers accept starting a prescription, stopping a prescription, increasing, decreasing, and even refilling. Now, there are some payers out there that don't consider refilling as prescription drug management, but most do, all right? But here's the thing, you got to tell us, they're on a prescription. So how many PPI medications, how many constipation medications are what? Over-the-counter, but they're also provided in script form. I don't know if you gave that patient a prescription or told them to go to Walmart and refill it, unless you tell me, all right? So in your plan of care, continue patient on XYZ at this dose, refill sent to the pharmacy, okay? That to me is a prescription, you're managing it, you're in control of it, okay? What I don't like to see, which I see a lot when we do reviews, is number one, GERD, continue current medications. I have no idea what that means, okay? Are you talking about their PPI? Is it over-the-counter? Is it a prescription? What are you talking about? You got to tell me, all right? And no, I'm not going to go look up in the medication list that the patient is on and try to determine it, because here's the thing, most of your patients, unfortunately, are on a lot of medications and you're not managing all those medications. So again, if you're managing them and you're continuing them, refilling them, things like that, you need to put it in your plan of care. Another one's decision for minor surgery with patient-identified risk factors, all right? So diagnostic endoscopy is considered a minor surgery, unless you tell me otherwise, okay? And I think most of you listening in would agree, a basic upper-lower endoscopy would be considered a minor surgery, okay? But again, we have patients that have risk factors. We have patients that you might do an advanced procedure on them that's high risk, or an ERCP on a patient that, you know, is very sick. There's all these different things that, again, if it changes the risk because of this patient, you need to say why. So minor surgery with identified patient or procedure risks, you just say it. Why are they higher risk? And we've got some examples later on, okay? We've got some clinical examples later on. We've got elective major surgery with no risk factors. This is kind of a new one that we need to kind of start getting used to. It's social determinants. So remember, Kathy went over the more, it seems like every year we're getting more new diagnosis codes for noncompliance. That is a social determinant, okay? So if the diagnosis or treatment is significantly limited by social determinants of health, and you elaborate on that in your plan, that also falls under moderate risk, okay? So your patient that you've told them to take their PPI now for months and months and months and months, and every time they come see you, they say they don't take it, or they can't afford it, or this, that, and the other, and now they've got what? Now they have an ulcer, all right? So that what? That increases cost. And that diagnosis is what? Tied to your claims. So there are situations where noncompliant patients should be reported, okay? But there are also other social issues. There are housing, food insecurity, patients that are homeless, patients that, again, noncompliant, social issues, family issues, work issues, any of that, those sort of things can play a role there. High risk, drug therapy requiring intensive monitoring for toxicity, decision for major surgery with identified risk factors, emergency major surgery, and guys, the decision for emergency major surgery can also be endoscopic services, okay? AMA, there's fine details within all of this. I'm just giving you the main points, okay? But I just wanted to let you know that. Decision not to resuscitate or to deescalate care because of poor prognosis, decision for hospitalization or escalation of hospital level of care, and then parenteral controlled substances, okay? So those are some examples of high risk. All right, so the number and complexity of problems addressed, a couple of things here. I'm not going to read all this to you, but number one, you have to address them or they have to impact your decision making, okay? I sometimes, when I do reviews, I see 20 diagnosis codes sitting in that assessment, and I'm like, there is no way we addressed all of these 20 things, okay? And most of the time there's not. So what I do, if you use a format of, I have my assessment up here, I have my plan down here, me as an auditor, I go and I connect the dots, okay? So if you order labs for XYZ, that's supported. If you order endoscopy for this, you put the patient on the medication for this, that's supported. But if I have eight more diagnosis codes where I have no idea what you're doing with them, I'm not counting them as a problem addressed, okay? So you have to address them or, again, you have to comment on how they impact decision making. Data, again, we talked about these are previous records, test ordered, and it says this includes information obtained from multiple sources or interprofessional communications that are not separately reported, okay? So one big thing on this one, if you bill for that service, you can't count that in your data component for your level, all right? So ordering endoscopies, you're billing for the endoscopy. Ordering capsules, you're billing for the capsule. Ordering FibroScan, you're billing for the FibroScan, okay, if you do those. And if they're in your, you know, in-house and you're billing for those services anyway, you can't count that in your data. You can count outside stuff, so labs, CTs, MRIs, things like that. And again, I talked about the last bullet here. Ordering a test is included in the category of test results and the review of the test is a part of that encounter and not a subsequent encounter. So it's one or the other. Again, risk of complications, morbidity, or mortality of patient management. Ultimately, again, ultimately, it is up to the provider to document the level of risk. But you have to tell us specifically. That's the best practice recommendation. If not, who are you leaving it up to? You're leaving it up to the payer that may not want to pay you for a higher level visit. Okay, when you leave it up to them, you know, it could, it could depend on the auditor. Auditor might be having a good day and decide with you. They might be having a bad day and say, nope, it's a level four, not a five. So because you've left it so gray for them, all right, so again, best practice recommendation. All right, time billing. So for time billing, again, Kathy kind of talked about it with the updates on the thresholds for your visits. We don't have those ranges anymore in the office. They're just straight shot visits. That's what it is. Okay. You have to meet that or exceed it. So it's no longer just face-to-face, but it is time spent on the day of the visit. Okay. So you have to do it on the day of the visit. So you have to do it on the day of the visit. So what, what types of things can you perform? What can you do that can be included in your time documentation? Well, preparation, reviewing tests, reviewing history, your exam, your evaluation, ordering, any time that takes you to order medications, tests, or other procedures, referring and communicating with other healthcare professionals can doc, when not separately reporting that service, documenting clinical information in the medical record, interpreting tests that you're not separately reporting, care coordination that you're not separately reporting. Okay. So all of those types of services can be reported. And guys, this is provider time. All right. So if your nurse spends 45 minutes trying to put an order in for a procedure or schedule it, that doesn't count. All right. But if you're talking to the nurse about the order and what we need to do and what the diagnosis code, that counts. It's your time, provider time. So here are your outpatient time thresholds. So again, you've got the level of service here to the left, and then to the right is your time spent. So you have to meet or exceed that time threshold. So you've got your new patients in the office, your follow-ups in the office, and then your consultations are on the far right, and the time supported there. You've got your consultations in the hospital and the time threshold, your initial inpatient or observation services with time, and your follow-up inpatient observation services with time. So documentation tips. Remember your HPI tells the story of the patient, whether new or established. Put all pertinent information in this area regarding current symptoms and abnormalities. Often data review is contained in this paragraph. And do not forget your chief complaint. Gotta have a chief complaint. And chief complaint needs to be specific, not just here for follow-up. I don't know what that means. You gotta tell me. Follow-up of hepatitis, follow-up of IBD. And also make sure your chief complaint is accurate. And I'll get into that on my later talk when we talk about electronic medical records. The impression and plan also contain what you are addressing, what you think it might be. So differentials are good. When you put your differentials in, it lets me know what you're thinking, what your thought process is, what is causing these issues. Okay, so differentials are good. Why are you ordering additional test procedures, instructions given to the patient, and other recommendations? List all conditions that you are currently managing and or that play a role in the care of the patient. If not documented, no one knows what you did or what you're doing. This is not just for supporting the level of service, but it's for medical necessity and preauthorization of tests and procedures. Okay, it all comes full circle. Even though the history and exam don't directly factor into your level, they still must be pertinent to the patient's chief complaint. For example, if the patient comes in with abdominal pain, you would expect to see an abdominal exam performed and documented. And guys, I don't see that a lot. I see office visits now where we hardly have exams. And again, if a patient comes in with new epigastric pain, you're probably examining their abdomen. I hope you are. Okay, so that needs to be documented. Another example, if the patient comes in with elevated transaminase, the social history specific to drugs and alcohol should be documented, as well as any family history of GI diseases or malignancies. All right, so thank you for listening to that talk. And that kind of segues into my next talk, which is all of that, all those details, all of those rules, et cetera, are now going to be put into clinical examples.

evaluation and management services

E&M services guidelines

2021 and 2023

medical decision-making

levels of complexity

time billing

documentation tips

clinical examples