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

Overview of E&M Documentation Guidelines - A Physician’s Perspective

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

Keywords

Evaluation and Management

E&M documentation

medical coding guidelines

CMS rules 2021-2023

medical decision making

social determinants of health