2024 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2023-02 - Overview of E and M Documentation Guidelines

02 - Overview of E and M Documentation Guidelines_Vaughn

Pdf Summary

This document provides an overview of the E&M (Evaluation and Management) guidelines for 2023. The guidelines include changes to codes for hospital inpatient and observation care, consultations, emergency department services, nursing facility services, and home or residence services. Some codes have been deleted, and others have been revised.<br /><br />The guidelines emphasize the importance of medical decision-making, which is determined by factors such as the number and complexity of problems addressed, the amount and/or complexity of data reviewed, and the level of risk. Time billing is also discussed as an alternative method for reporting E&M services, with guidelines provided for both outpatient and inpatient/observation services.<br /><br />Documentation tips are provided, including the importance of including relevant information in the history of present illness and impression/plan sections. The history and physical examination are still considered important components of the visit, even though they don't directly factor into the level of service.<br /><br />The document concludes with the contact information for the presenter, Kristin Vaughn, who is a healthcare consultant and lead auditor.

Keywords

E&M guidelines

2023

hospital inpatient care

observation care

consultations

emergency department services

nursing facility services

home or residence services

medical decision-making

time billing