ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand) | April 2022-01_Fundamentals_GI_Consultation Note

01_Fundamentals_GI_Consultation Note - Olmstead

Pdf Summary

The article discusses the fundamentals of a gastroenterology consultation note. The three components of a consultation are referred to as referral, render, and report. Medicare does not cover outpatient consultation codes 99241-99245. The article also covers the evaluation and management coding guidelines, emphasizing the importance of capturing clinical concepts and correct coding. It explains the different components of the evaluation and management guidelines, including history, review of systems, past medical history, family medical history, social history, history of presenting illness, physical examination, and medical decision making.<br /><br />The coding guidelines for new consultations and established patients are also explained, along with the levels of service for different codes. Time-based coding is also discussed, which includes the total time spent on face-to-face interaction and pre/post documentation. The article provides a case study of a GI consultation and describes how to document the history of presenting illness, physical examination, and medical decision making.<br /><br />The article also discusses best practices in patient communication, such as being uncomplicated, specific, and using repetition. It highlights the importance of requesting previous records, communicating findings and next steps to the patient, documenting relevant data, and communicating with referring providers and referrals. The article concludes by mentioning the CMS evaluation and management guidelines and providing some practice pearls.<br /><br />Overall, the article covers the key aspects of a gastroenterology consultation note, including coding guidelines, documentation requirements, and effective patient communication.

Keywords

gastroenterology consultation note

referral

render

report

Medicare

evaluation and management coding guidelines

history

physical examination

medical decision making

patient communication