Expert Article

Expert Article 

The American College of Emergency Physicians (ACEP) updated their FAQs on the 2023 Emergency Department Evaluation and Management Guidelines in November 2023. The FAQs attempt to further clarify ACEP’s original FAQ document that was published not long after the new guidelines were released. The FAQs are available here: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs

The biggest 2023 guideline changes for emergency medicine include the following:
1. Revision of the code descriptor for E/M code 99283 from low-moderate MDM to low MDM.
2. Revision of the code descriptor for E/M code 99284 from high-moderate MDM to moderate MDM.
3. While a medically appropriate history and physical exam should still be performed by the treating emergency medicine provider, history and exam are no longer elements in E/M code choice selection.
4. E/M code selection is now based on Medical Decision Making or time. As time is not used to select ED E/M level codes 99281 – 99285, MDM drives E/M code selection.
5. Modifications have been made to the criteria for determining the level of Medical Decision Making as mostly represented in the Risk column. Billing and coding companies are still permitted to use prior code choice criteria to help differentiate each Evaluation and Management level choice.

By now, coders should be familiar with the AMA’s 2023 Guidelines and the COPA, Data and Risk elements that are used to determine an E/M Level of service. As in the past, two of three columns in the MDM Table of Elements are needed to achieve a level of service. The COPA and Data columns are clear and simple to use once a coder understands the definitions and explanation included in the AMA document.

That said, the Risk column for the moderate and high levels of service clearly states that the items that are published in the column are “examples only.” When asked for clarification or additional examples of risk, the AMA/CPT indicated that it would not be possible to list all the possible patient management decisions that need to be considered when calculating the level of risk for an E/M service. Specifically, the AMA stated that physicians/QHPs have a common understanding of how diagnostic and therapeutic decisions are made and that the assignment of risk should be based on the usual behavior and thought processes of physicians from the same specialty.

Although this opens the door for consideration of other examples in the risk column, emergency physicians do not generally assign codes for their patients, leaving coders left to determine an E/M Level of service whether they have a clinical background or not. Some coding companies and compliance officers have decided to use the 2023 Guidelines exactly as published by the AMA. In many cases, this leads to significant under-coding of records because MDM is determined to be low rather than moderate or moderate rather than high. Either way, both scenarios result in significant financial loss to the ED group.

In the November 2022 issue of CPT Assistant, it was clarified that MDM should focus primarily on physician/QHP work performed and decisions made during the EM encounter. The level of risk associated with a patient’s treatment can vary based on the patient’s current health status, medical history, and management decisions made during the visit.
Many factors must be considered when determining risk. These include, but are not limited to:
• CT scans present risk to the patient due to high exposure of the patient to radiation and contrast when used. When a provider orders multiple special studies or a CT with contrast, the patient is at high risk. Ordering one special study generally starts at a moderate level of risk whereas multiple special studies generally start at a high level in the risk column. Of note also is that children are more susceptible than adults to radiation exposure because they have developing organs and tissues.
• Order of any medication that cannot be administered without a prescription is considered prescription drug management. This starts at moderate risk and includes medications that are given for procedures such as incision and drainage and laceration repair.
• Radiation from x-rays also poses a risk to patients. Radiation exposure to extremities is less than radiation needed for more anatomically centralized x-rays such as lumbar spine, chest, or abdominal films.
• Administration of IV fluids presents different risks to different patients. There is always a risk of infection when a catheter is inserted into a vein. In addition, some patients are more susceptible to fluid overload which can lead to potentially life-threatening conditions such as pulmonary edema. IV fluids represent at least moderate risk to any patient who receives this form of therapy.
• Some medications present a high risk for patients, including those that require intensive monitoring for toxicity, or when several medications are given during the same visit.
• Pregnant patients are generally at higher risk than those who are not pregnant. There are categories of medications that present risks to the fetus.
• In the emergency department, there are procedures that must be performed “immediately or with minimal delay to allow for patient stabilization. Some of these procedures may be considered major surgery. For example, displaced fracture care, reduction of a dislocated joint, a chest tube, lumbar puncture are all considered high risk.
• The decision to initiate or forgo further testing or hospitalization is considered medical decision making.
• Moderate sedation is associated with high risk.
• Patients who require physical or chemical restraints are at high risk of physical injury, psychological trauma, respiratory, and/or circulatory compromise.

In summary, while the 2023 Guidelines have relaxed the formerly required components of documentation for history and physical, medical decision making is now the sole determinant of an E/M Level of Service, rendering interpretation of MDM level on the diagnoses that a provider is attempting to confirm or rule out given the studies and therapeutic interventions that are ordered, as well as how diagnostic and therapeutic decisions affect the risk to a patient from workup and treatment. Encounters can be significantly under- or over-coded if providers do not understand the documentation requirements needed to support MDM. In addition, unless emergency medicine coders are armed with the proper, specialty-specific tools that contain objective criteria for the Risk element of the MDM table there will be risk of compliance problems and revenue loss.