2024 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2023-03 - E&M Examples Medical Decision Making and Time Driven Visits

Pdf Summary

This document provides a set of clinical examples for both medical decision-making and time-driven visits. Example #1 discusses an established patient with irritable bowel syndrome (IBS-C) who is stable and requires a continuation of medications. Example #2 involves an established patient with irritable bowel syndrome (IBS) experiencing increased stress factors, requiring a medication adjustment and a referral for psychiatric counseling. Example #3 features a new patient with left upper quadrant abdominal pain and a history of gastric ulcer, who requires a medication change and additional tests. Example #4 presents a new patient with acid reflux symptoms, requiring further evaluation to rule out Barrett's esophagus. Example #5 illustrates an initial hospital visit for a patient with gastrointestinal bleeding and acute blood loss anemia, necessitating urgent endoscopy. Example #6 showcases a hospital follow-up visit for a patient with resolved gastrointestinal bleeding. The document also includes examples of endoscopic risks, highlighting the assessment and plans for different scenarios. Lastly, there are two examples illustrating time billing based on the total time spent with the patient during the encounter.

Meta Tag

Concept Evaluation and Management Coding

Concept Medical Decision Making

Concept Problems Addressed

Concept Data Reviewed

Concept Risk

Keywords

clinical examples

medical decision-making

time-driven visits

irritable bowel syndrome

medication continuation

medication adjustment

referral for psychiatric counseling

gastric ulcer

Barrett's esophagus

gastrointestinal bleeding

Evaluation and Management Coding

Medical Decision Making

Problems Addressed

Data Reviewed

Risk