2026 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2025-Examples for both Medical Decision Making and Time Driven Visits

Pdf Summary

This presentation by Kristin Vaughn, a healthcare consultant and lead auditor, focuses on Evaluation and Management (E&M) coding, specifically illustrating medical decision making (MDM) and time-based billing through clinical examples.<br /><br />The session starts with detailed cases categorized by MDM complexity levels—minimal, low, moderate, and high—along with corresponding CPT codes. For instance, new and established patient visits are demonstrated with assessments of conditions like GERD, IBS-C, liver cirrhosis, and ulcerative colitis, including associated plans and risk assessments. Cases progress from straightforward management of stable conditions to more complex scenarios such as acute GI bleeds requiring urgent endoscopic procedures.<br /><br />Endoscopic risk examples underscore how patient comorbidities and procedure urgency influence MDM complexity and coding, ranging from low-risk scheduled endoscopies to high-risk emergent ERCPs in pancreatic cancer.<br /><br />Time-based billing is exemplified in follow-up visits, showing how total time spent on a patient encounter—including history, examination, record review, and documentation—determines appropriate CPT codes. Tables summarize CPT codes paired with their respective time thresholds for office and hospital outpatient services.<br /><br />Documentation tips emphasize accurately capturing the complexity of problems addressed, data reviewed (lab tests, imaging, external records, independent historians), and risks involved, including social determinants of health and procedural risks. The presentation highlights the importance of using clear lay language and key risk descriptors (urgent, emergent, high-risk, life-threatening) to support coding choices.<br /><br />Overall, the webinar provides a comprehensive guide to applying MDM criteria and time-based billing principles in gastrointestinal clinical settings, ensuring appropriate reimbursement and compliance with AMA CPT standards.

Asset Subtitle

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

Keywords

Evaluation and Management coding

Medical Decision Making

Time-based billing

CPT codes

MDM complexity levels

Gastrointestinal clinical cases

Endoscopic risk assessment

Follow-up visit documentation

Healthcare compliance

Kristin Vaughn