Inpatient Evaluation and Management Documentation and Coding for 2023 and Beyond-Session Presentation

Video Transcription

Video Summary

Linda Duckworth, a billing and coding expert, provides insights into the new inpatient E&M coding guidelines and offers guidance for accurate coding practices. The new guidelines focus on medical decision-making and time, rather than history and physical exams. Providers are encouraged to eliminate unnecessary details from their notes and focus on relevant information for each visit. Linda emphasizes the importance of documenting chronic and acute conditions, as well as the status and goals of each condition. Detailed assessments and plans that reflect the complexity of each patient's problems are crucial. Linda discusses the three key components of medical decision-making: problems addressed, data reviewed or ordered, and risk associated with management decisions. Different levels of complexity are explained using examples. Risk is determined by the treatment plan and not solely based on the medical condition. The importance of documenting discussions, interpretations, or consultations with other healthcare professionals is highlighted. The speaker also addresses challenges in coding and documenting medical records, such as accurately documenting patient complexity, data points, and risk factors. The difficulty of determining billable services and precise documentation of time spent on each encounter are discussed. Seeking guidance from coding experts or auditors is recommended for accurate coding and documentation. Case studies are provided to illustrate coding and documentation principles. Thorough and accurate documentation is stressed as essential for proper coding and billing for medical services.

Keywords

Linda Duckworth

billing and coding expert

inpatient E&M coding guidelines

accurate coding practices

medical decision-making

eliminating unnecessary details

chronic and acute conditions

detailed assessments and plans

risk associated with management decisions

documenting discussions and consultations

thorough and accurate documentation