2025 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2024-E&M Examples for both Medical Decision Making & Time Driven Visits

Video Transcription

Video Summary

The provided transcript is a comprehensive overview focused on the importance of documentation in Evaluation and Management (E&M) for medical providers, with particular focus on decision-making and time-based billing. The speaker, likely addressing an audience involved in healthcare documentation, discusses various clinical examples to illustrate how different scenarios align with E&M coding guidelines. Emphasis is placed on creating coherent and specific documentation that highlights the chief complaint, assessment, and plan. The speaker walks through clinical case examples, emphasizing the need to document decision-making components such as complexity, data, and risk. They demonstrate how these elements affect the level of service code (e.g., 99213, 99214), exploring various patient scenarios, such as established patients with chronic conditions, new patients with undiagnosed problems, and hospital visits. The speaker also covers documentation connected to endoscopic procedures and time-based considerations, advising that, in some cases, time spent on patient care (including preparation, discussion, and documentation) can impact billing levels. Additionally, the necessity of clearly documenting prescription management and differentiating risk factors during procedures is highlighted. The session ends with a Q&A segment for further inquiry into the discussed topics.

Asset Subtitle

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

Keywords

E&M documentation

decision-making

time-based billing

clinical examples

service code levels

risk assessment

healthcare documentation