On Demand: Complex E/M Coding and Documentation-Webinar Recording

Video Transcription

Video Summary

Nicole Knight and Linda Gage-Stribbe discuss the 2021 and 2023 guidelines for medical billing and coding in this video transcript. They cover topics such as documentation, note signing, chief complaint, medical decision-making, split shared services, critical care, CMS add-on visit complexity, and more. They stress the importance of accurate and detailed documentation for each level of service. They address common challenges and misconceptions, including the use of copy-pasted notes, the definition of new and established patients, and the documentation of time for billing purposes. They also provide recommendations for meeting the documentation requirements. They then delve into split shared services in hospitals and outpatient clinics, clarifying the requirements for each provider involved. They explain the nuances of billing for critical care, emphasizing the need to document the time spent separately from any procedures performed. The speakers discuss the use of prolonged services codes, noting the differences between Medicare and commercial payers in recognizing and reimbursing these codes. They also touch on the proposed complexity code and its potential impact on medical billing, highlighting that its implementation is uncertain. They offer examples of complexity that may be eligible for billing. Finally, they address common questions and comments related to billing, coding, modifiers, and caution against billing for services that may be subject to change based on future congressional decisions.

Keywords

2021 guidelines

2023 guidelines

medical billing

coding

documentation

split shared services

critical care

CMS add-on visit complexity

accurate documentation

prolonged services codes

Medicare

commercial payers

complexity code