ASGE Annual GI Advanced Practice Provider Course - Day One | July 2021-03_Case Study I Outpatient New Consult and Follow-up Note

03_Case Study I Outpatient New Consult and Follow-up Note - Olmstead

Pdf Summary

This case study discusses outpatient consultation and follow-up notes, focusing on evaluation and management coding guidelines and the importance of capturing clinical concepts. The study also reviews key concepts of correct coding and outlines the elements of utilizing consultation codes. Additionally, it provides an overview of televisit coding guidelines.<br /><br />The study emphasizes the evaluation and management guidelines, which include components such as history, review of systems, past medical history, family medical history, social history, history of presenting illness, physical examination, review of data, and medical decision making. It explains the coding guidelines for new and established patients, specifying the required components for each level of service.<br /><br />The case study presents three patient scenarios, each discussing the history of presenting illness, physical examination, and medical decision making. It provides examples of the elements of medical decision making and includes ICD-10-CM and CPT codes for each case.<br /><br />In the last section, the study briefly summarizes the interim CMS coding guidelines for telehealth visits and provides links to relevant resources for further information.<br /><br />Overall, this case study provides a comprehensive overview of outpatient consultation and follow-up notes, including coding guidelines and examples of patient scenarios. It aims to educate healthcare professionals on proper coding practices and highlights the importance of accurately documenting clinical concepts.

Keywords

outpatient consultation

follow-up notes

evaluation and management coding guidelines

capturing clinical concepts

correct coding

utilizing consultation codes

televisit coding guidelines

history

physical examination

medical decision making