ASGE Annual GI Advanced Practice Provider Course - Onboarding Day One (On-Demand) | 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. It emphasizes the importance of capturing clinical concepts and reviews key concepts of correct coding. The document discusses the elements involved in utilizing consultation codes and provides an overview of televisit coding guidelines.<br /><br />The evaluation and management guidelines are outlined, including 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. Coding guidelines for new and established patients are also discussed.<br /><br />New patient visits/consultation codes and established patient visits are further explained, with levels of service and corresponding codes provided. The requirements for consultation services are outlined as referral, rendering an opinion, and reporting back to the referring provider.<br /><br />The document includes three case studies. Case 1 is a new patient/consultation visit for a 45-year-old male with diarrhea. Case 2 is an established visit for a 65-year-old male with dysphagia. Case 3 is a televisit for a 72-year-old female with constipation. Each case provides detailed information on the history of presenting illness, physical examination, differential diagnosis, and management plan. The corresponding ICD-10-CM and CPT codes are also provided.<br /><br />The document concludes with additional resources and recommendations, including CMS telehealth guidelines and resources for evaluation and management services.<br /><br />In summary, this case study provides a comprehensive overview of outpatient consultation and follow-up notes, including coding guidelines and examples for different scenarios. It emphasizes the importance of accurate coding and documentation in healthcare settings.

Keywords

outpatient consultation

follow-up notes

evaluation and management coding guidelines

clinical concepts

correct coding

consultation codes

televisit coding guidelines

history

review of systems

past medical history