Guidelines: Test Your 2021 E/M Coding Guideline Expertise with 3 Examples

Why This Topic Matters

The article is useful for anyone applying the 2021 office/outpatient E/M rules in gastroenterology, because it highlights how documentation details, time reporting, and medical decision making affect visit-level coding accuracy.

Article Sections

1. Example 1: Decide MDM Or Time?

   A scenario involving an established patient encounter and discussion of how visit level may be evaluated using either time or medical decision making. The section also touches on documentation elements reviewed in support of the visit.

2. Example 2: Don’t Neglect Substance

   A new patient scenario centered on limited gastrointestinal findings and documentation quality. The section focuses on how the note is assessed under the 2021 E/M framework.

3. Example 3: When MDM and Time Align

   A second established patient scenario showing how time and medical decision making are considered together. The section includes documentation features relevant to the overall E/M assessment.