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

Video Transcription

Video Summary

This 30-minute overview covers Evaluation and Management (E&M) documentation guidelines essential for clinicians, coders, and practice managers to optimize billing and reduce administrative burden. Updated CMS rules, effective since 2021-2023, focus medical coding on relevant history, physical exam, and medical decision making (MDM), eliminating unnecessary documentation. Billing relies on two methods: medical decision-making—evaluated by problems addressed, data reviewed, and risk of complications—or time spent on patient care and documentation. Proper documentation of social determinants of health (SDOH) using ICD-10 Z-codes can influence risk levels and billing. Accurate, specific, and clinically relevant notes, especially in assessment and plan, maximize billing levels and compliance. Time-based billing includes both face-to-face and non-face-to-face activities, with clear breakdowns required for auditors. The talk emphasizes that appropriate documentation of E&M visits is increasingly valuable as procedural reimbursements decline, urging providers to capture full credit for non-procedural work. Resources for ongoing coding questions are provided.

Asset Subtitle

Edward Sun, MD, MBA, FASGE

Meta Tag

Concept EM Documentation

Concept Medical Decision Making

Concept Problems Addressed

Concept Data Reviewed

Concept Risk

Keywords

Evaluation and Management

E&M documentation guidelines

CMS coding rules 2021-2023

medical decision making

social determinants of health

time-based billing

EM Documentation

Medical Decision Making

Problems Addressed

Data Reviewed

Risk