Expert Article: 2023 Emergency Department Evaluation and Management Guidelines Q&A!

Expert Article: 2023 Emergency Department Evaluation and Management Guidelines Q&A 

Practices will be using a new set of E/M documentation and coding guidelines for ED visits in January of 2023. The new DGs seek to provide continuity across E/M sections allowing for revisions implemented in the E/M office visit section in 2021 to extend to all other E/M sections – including emergency medicine and hospitalist E/M codes – with revisions to the Levels of Medical Decision (MDM) Table and retirement of some codes.

A proactive approach to provider and coder training and a thorough understanding of the new DGs is imperative and will ensure compliance and keep the revenue flowing as you implement changes to the Evaluation and Management section of CPT® in your organization. Since implementation of the new DGs has been announced, we have received many questions about the biggest changes and the gray areas.  Let’s begin with some Q&A specific to the practice of emergency medicine.

Q: Where can I download a copy of the new 2023 DGs and when will the new guidelines be implemented?

A: The 2023 DGs can be downloaded here: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Implementation of the new guidelines is set to occur on any service billed beginning January 1, 2023.

Q: Will emergency medicine be using a new set of E/M codes to report emergency medicine services?

A: While the codes used in emergency medicine have not changed, the code descriptors have been revised. The emergency medicine E/M definitions have been updated to correlate with the change in E/M coding guidelines to select the E/M code based exclusively on Medical Decision Making. The 2023 emergency medicine code descriptors are as follows:

  • 99281 –Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
  • 99282– Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making.
  • 99283– Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision-making.
  • 99284– Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate medical decision-making.
  • 99285– Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision-making.

Q: With regard to emergency medicine, how do the 2023 DGs differ from the 1995 and 1997 DGs?

A: For emergency medicine, the most significant changes include the following:

  • The elimination of history and physical exam as elements for code selection.
  • E/M code selection is based on Medical Decision Making or Total Time. As time is not a component in the ED, MDM will be used to select final E/M codes.
  • Modifications to the criteria for determining the level of Medical Decision Making (MDM).

Q: As documentation of a pertinent history and exam are no longer required for E/M code choice, does that mean that emergency medicine providers no longer have to document the elements?

A: While the history and exam do not directly contribute to selecting the E/M code, the emergency department E/M code descriptors stipulate that a medically appropriate history and/or physical examination should be performed and documented, and that the nature and extent of both should be determined by the treating physician or Qualified Healthcare Professional (QHP) who is performing these services.

That stated, the MDM grid quantifies the complexity of problems addressed with measurable statements such as undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, or chronic illnesses with severe exacerbation to name a few. While the history and exam elements no longer count towards selection of an E/M code, a descriptive history and exam will ensure that coders understand the complexity of the problems that were addressed during the course of the encounter and help them determine the final level of medical decision-making with accuracy.

Q: As the 2023 CPT manual continues to state that time is not a descriptive component for emergency medicine services will time still be utilized to code Critical Care codes 99291-99292?

A: Yes, time will continue to be utilized when assigning critical care codes 99291-99292

Q: What are the modifications to the criteria for determining Medical Decision Making?

A: While minor changes have been made to the three current MDM subcomponents, extensive changes will impact the process of “scoring” MDM elements for E/M code choice. The current CMS Table of Risk and other contractor tools were used as the basis for designing the new required elements for MDM.

The new DGs define concepts that were previously vague (e.g., “Chronic illness with exacerbation, progression, or side effects of treatment”) and provide definitions for important terms, such as “independent historian” and “discussion.” Furthermore, the ongoing discussion between new vs. established problem and no additional workup vs. additional workup planned has been eliminated. The Complexity of Data Reviewed component also garners a point for each unique test ordered/reviewed, review of prior external notes, and history from an independent historian.

Perhaps the most impactful changes for emergency medicine include the following:

  • The cognitive effort of considering testing or treatment that may not be performed is recognized as contributing to the complexity of the MDM.
  • Assessing the risk vs. benefit of hospital admission is recognized as a high-risk decision, even if the patient is ultimately discharged or sent to rehabilitation or a skilled nursing facility.
  • Multiple problems of a lower severity may, in the aggregate, create higher risk due to
  • The final diagnosis is not the sole determining factor for an E/M code. Presenting symptoms likely to represent a highly morbid condition may require an extensive evaluation. These extensive diagnostic and/or therapeutic interventions that are ordered to confirm or rule out a highly morbid condition will determine MDM even if the ultimate diagnosis is not highly morbid. All evaluation and/or treatment should be consistent with the likely nature of the condition.

Q: How will Medical Decision Making be determined now that the Marshfield Clinic Scoring Tool is to become obsolete in 2023?

A: Within the E/M section of CPT, a new grid is used to measure or “score” the MDM.  A combination of the following three components determines the final MDM level:

  1. The number and complexity of problem(s) addressed during the encounter (COPA).
  2. The amount and/or complexity of data to be reviewed and analyzed (DATA).
  3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s) (RISK).

The Levels of Medical Decision Making (MDM) table is a guide to assist in selecting the level of MDM for reporting an E/M services code. The table includes the four levels of MDM (i.e., straightforward, low, moderate, high) and the three elements of MDM (i.e., number and complexity of problems addressed at the encounter, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). To qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded. The final Level of MDM is based on 2 out of 3 elements being met.

Q: How is COPA measured?

A: One element used in selecting the level of service is the number and complexity of the problems that are addressed during the course of the encounter. CPT divides the four levels of MDM as follows: Straightforward, Low, Moderate, or High. COPA is broken down into four measures – Minimal, Low, Moderate, and High – each of which includes “problems” that are also defined in the new DGs.

When assigning a COPA level, the following must be considered:

  • A problem has been addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional (QHP) reporting the service. This includes consideration of further testing or treatment that may not be performed by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.
  • Multiple illnesses or injuries that may be low severity as standalone presentations can increase the complexity of the MDM when combined in a single evaluation.
  • Comorbidities and underlying diseases can contribute to the MDM if addressed during the encounter.
  • Multiple problems of a lower severity may, in the aggregate, create higher complexity.
  • The final diagnosis does not determine the complexity or risk. An extensive evaluation may be required to conclude that the signs or symptoms do not represent a highly morbid condition. Presenting symptoms that are likely to potentially represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid.

Q: Does the 2023 CPT manual provide clinical examples for the bulleted “problem” descriptors in COPA?

A: No, the 2023 CPT manual does not provide clinical examples for the bulleted “problem” descriptors in COPA. The ACEP Coding and Nomenclature Committee has offered some guidelines for examples that are relevant to emergency medicine. Those guidelines can be found here: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs

 Q: Do comorbidities help determine an E/M level?

A: In order to impact the MDM level and ultimately the E/M level, documentation should reflect how the comorbidities impacted the MDM for the ED encounter. Per CPT, “Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”

 Q: How is the Amount and/or Complexity of Data to be Reviewed and Analyzed measured?

A: Amount and/or Complexity of Data to be Reviewed and Analyzed (Data) is divided into three categories:

  1. Category 1: Tests, documents, orders, or independent historian(s).
  2. Category 2: Independent interpretation of tests (not separately reported).
  3. Category 3: Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source.

The MDM grid in the E/M section of CPT assigns value to components of the Data categories. For each encounter, elements from each category are counted to determine if the Data is Minimal, Limited, Moderate, or Extensive.

Q: How are the bulleted items in Category 1: Tests, documents, orders, or independent historian(s) counted?

A: Each unique test, order, or document is individually counted to meet the indicated requirement for each level of Data. A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian, would be a combination of three elements.

  • Review of prior external note(s) from each unique source.
  • External notes are any records, communications, test results, etc., from an external physician/QHP, facility, or health care organization. For emergency physicians, these will be any notes that come from outside the emergency department, (e.g., inpatient charts, nursing home records, EMS reports, ED charts from another facility or ED group, etc.).
  • A unique source is defined as a physician/QHP in a distinct group, different specialty, subspecialty, or unique entity.
  • Medical records from prior visits to the same emergency department do not qualify as external records as they are from the same physician group/specialty.
  • Review of external notes from each unique source counts as one element when calculating the Data (e.g., a review of a discharge summary from a prior inpatient stay and review of nursing home records would each count as 1, for a total of 2 “points” for Category 1).
  • Review of the result(s) of each unique test.
    • Tests are imaging, laboratory, psychometric, or physiologic data.
    • The CPT code set defines a unique test.
    • A clinical laboratory panel (e.g., BMP (80047), is a single test).
    • When the same test is performed multiple times during an ED visit (e.g., serial blood glucose, repeat EKG), count it as one unique test.
    • For data reviewed and analyzed, pulse oximetry is not a test. Pulse oximetry is now considered a vital sign.
  • Ordering of each unique test.
    • Ordering a test is included in reviewing the results.
    • A single unique test ordered or reviewed is a data point, but a single unique test ordered and reviewed is not 2 points.
    • It is assumed that the physician/QHP will review the results of a test ordered; therefore, the physician/QHP does not receive dual credit in Category 1 for both ordering and reviewing the same test.
    • Review of a test ordered by another physician counts as a review of a test. For example, a review of tests performed at an outside clinic, urgent care center, or nursing home prior to arrival in the ED would qualify.

A combination of different Category 1 elements are summed to determine the total.

Q: Does “Assessment requiring an independent historian” count towards Category 1 or Category 2?

A: It depends on the Data level.  For Limited data, it is Category 2; for Moderate and Extensive, it is included in Category 1.

Q: If code 93010 is reported can I count Category 2 for independent interpretation of an EKG?

A: No, per CPT, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.”

Q: Who qualifies as an external physician/qualified health care professional or another appropriate source for Category 3?

A: An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty counts towards Category 3. This includes licensed professionals who are practicing independently, and facility or organizational providers from a hospital, nursing facility, or home health care agency.

Q: What qualifies as “discussion” for Category 3 – Discussion of management or test interpretation with external physician/other appropriate source?

A: A “discussion” requires an interactive exchange. The exchange must be direct and not through non-clinical intermediaries. Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a day or two.

Q: How are the Risk of Complications and/or Morbidity or Mortality measured?

A: One element used in selecting the level of service is the risk of complications and/or morbidity or mortality of patient management at an encounter. This is distinct from the risk of the condition itself.  According to CPT, risk is the “probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.”

 Q: What are some examples of procedures that would qualify as major and minor procedures in the ED?

A: Procedures performed in the ED that may be considered minor surgery may include, but are not limited to:

  • Simple wound repair
  • Foreign body removal
  • Incision and drainage.

Procedures frequently performed in the ED that may be considered major surgery may include, but are not limited to:

  • Endotracheal intubation
  • Chest tube
  • Cardioversion
  • Displaced fracture care
  • Reduction of an intermediate joint dislocation, (e.g., TMJ, acromioclavicular, wrist, elbow or ankle) or a major joint dislocation (e.g., shoulder, hip, or knee).

Note: Some of the major procedure examples are most commonly performed for Critical Care patients.

Q: What are social determinants of health (SDOH) that may indicate moderate risk?

A: Any economic or social condition that may significantly limit the diagnosis or treatment of a patient’s condition (e.g., inability to afford prescribed medications, unavailability or inaccessibility of health care). Common social determinants of health (SDOH) in the emergency department may include homelessness/undomiciled, unemployment, uninsured, and addiction.

Q: Does consideration of a test, treatment, or management option (e.g., admission vs. discharge) not ordered or performed contribute to the complexity of the medical decision making?

A: Yes, the need to initiate or forego further testing, treatment, and/or hospitalization/escalation in care can be a factor in the complexity of medical decision making. Examples in which the physician/QHP may elect not to order a test, treatment, or management option include but are not limited to a clinician’s risk/benefit analysis or use of evidence-based risk calculators, or shared decision making.

BSA Healthcare’s 2023 E/M Documentation Guidelines Emergency Medicine Coder Training Webinar Library

2023 DGs Emergency Medicine Provider Documentation Training Webinar Series

Dr. John Stimler of BSA Healthcare has recorded a four-part Emergency Medicine Provider Documentation Training Webinar Series that addresses the following topics:

Part One: 42 minutes

  • 2023 E/M Services Guidelines – Summary
  • Code Revisions
  • Emergency Medicine E/M Code Descriptors
  • Medical Record Documentation for EM Services
  • Medical Decision Making Levels

Part Two: 29 minutes

  • Medical Decision Making Component One: Number and Complexity of Problems Addressed at the Encounter (COPA)
    • How is problem defined and what does it include and not include?
    • Straightforward, Low, Moderate, and High COPA

Part Three: 41 minutes

  • Medical Decision Making Component Two: Amount and/or Complexity of Data to be Reviewed and Analyzed (DATA)
  • Data Categories and Definitions
  • Data Levels and Documentation Considerations – Limited, Moderate, and Extensive

Part Four: 28 minutes

  • Medical Decision Making Component Three: Risk of Complications and/or Morbidity or Mortality of Patient Management (RISK)
  • Biggest Changes
  • Moderate Risk and High Risk Examples
  • MDM Leveling Summary
  • Key Documentation Drivers
  • The GOOD News!

2023 DGs Emergency Medicine Coder Training Webinar Series

Dr. John Stimler of BSA Healthcare has recorded a four-part Emergency Medicine Coder Training Webinar Series that addresses the following topics:

Part One: 41 minutes

  • 2023 E/M Services Guidelines – Summary
  • Code Revisions
  • E/M Code Descriptors
  • General Principals of Medical Record Documentation

Part Two: 36 minutes

  • Medical Decision Making Component One: Number and Complexity of Problems Addressed at the Encounter (COPA)
    • How is problem defined and what does it include and not include?
    • Straightforward, Low, Moderate and High

Part Three: 43 minutes

  • Medical Decision Making Component Two: Amount and/or Complexity of Data to be Reviewed and Analyzed (DATA)
  • Data Categories and Definitions
  • Data Levels and Documentation Considerations – Limited, Moderate, and Extensive

Part Four: 46 minutes

  • Medical Decision Making Component Three: Risk of Complications and/or Morbidity or Mortality of Patient Management (RISK)
  • Biggest Changes
  • Moderate Risk and High Risk Examples
  • MDM Leveling Summary
  • Key Documentation Drivers
  • 2023 E/M Coding for Emergency Medicine Services
  • The GOOD News!

Please call 888-568-4993 for deliverables and fee information.