2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Overview of E&M Documentation Guidelines

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This presentation by Edward Sun, MD, MBA, FASGE, Associate Chief Medical Officer at Peconic Bay Medical Center and Chair of the ASGE Reimbursement Committee, provides an overview of the 2026 Evaluation and Management (E&M) documentation and billing guidelines, emphasizing important updates for physicians and practices. <br /><br />The 2026 E&M guidelines simplify outpatient and inpatient visit documentation requirements, building on prior reforms such as the Patients over Paperwork Act of 2021 and 2023 documentation reductions. The new approach enables billing based primarily on Medical Decision Making (MDM) or Time spent on the day of the encounter, rather than extensive history and physical exam documentation.<br /><br />MDM is assessed using three components: 1) Number and complexity of problems addressed, 2) Amount and complexity of data reviewed and analyzed, and 3) Risk of complications, morbidity, or mortality from patient management. Each element is categorized from minimal to high complexity, and the level of MDM (straightforward to high) determines the appropriate CPT codes for new and established outpatient visits as well as hospital inpatient or observation care. The “best two out of three” criteria apply for determining MDM level. Observation codes have been eliminated.<br /><br />Billing by time counts all activities on the day of the visit, including reviewing tests, ordering medications, documentation, and care coordination, rather than just face-to-face time. Time ranges correspond to specific CPT codes for outpatient and inpatient visits. <br /><br />The presentation also highlights social determinants of health (SDOH) ICD-10 Z-codes (e.g., financial or food insecurity) that can be documented to support patient risk assessment and reimbursement. Changes in wRVUs for common endoscopy CPT codes and E&M codes from 2025 to 2026 are noted, reflecting updated valuation.<br /><br />Resources include ASGE coding primers, practice support links, Medicare fee schedule look-ups, and contact information for coding guidance. The overall goal is to help physicians adapt to evolving coding, documentation, and reimbursement regulations to optimize practice productivity and compliance.

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Edward Sun, MD, MBA, FASGE

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Concept Evaluation and Management Coding

Concept Medical Decision Making

Concept Documentation Requirements

Concept Total Time

Concept Problems Addressed

Keywords

2026 E&M guidelines

Medical Decision Making

Time-based billing

Outpatient documentation

Inpatient visit coding

CPT codes

Social determinants of health

ICD-10 Z-codes

ASGE reimbursement

wRVU changes

Evaluation and Management Coding

Medical Decision Making

Documentation Requirements

Total Time

Problems Addressed