ACEP ID:
1. Are there new E/M codes to report emergency physician services for 2023?
The codes have not changed, but the code descriptors have been revised. In November 2019, CMS adopted the AMA’s revisions to the Evaluation and Management (E/M) office visit CPT codes (99201-99215), code descriptors, and documentation standards. The revised CPT guidelines for office/outpatient E/M codes went into effect on January 1, 2021
On July 1, 2022, the AMA released additional revisions to the rest of the E/M code sections, including the ED E/M codes. The 2022 revisions will provide continuity across all the E/M sections.
The revised E/M codes, descriptions, and guidelines will apply to all E/M codes on January 1, 2023.
For 2023, ED 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.
2. How do the new guidelines differ from the existing guidelines?
The most significant revisions to the 2023 E/M Guidelines are:
3. Do these changes mean I am no longer required to document a history or exam?
While the history and exam don’t directly contribute to selecting the E/M code, the emergency department E/M codes stipulate that there should be a medically appropriate history and/or physical examination.
The nature and extent of the history and physical examination are determined by the treating physician/Qualified Healthcare Professional (QHP). Importantly, the extent of history and physical exam documented is not used to assign the E/M code.
However, the MDM grid measures the complexity of problems addressed with expressive statements such as acute, uncomplicated illness or injury, undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; chronic illnesses with severe exacerbation. While the history and exam elements are not “counted,” a descriptive history and exam will ensure the coder or auditor will understand the complexity of problems addressed to the extent necessary to determine medical decision-making accurately.
4. If E/M codes are selected based on Medical Decision Making or Total Time, do I need to document my time for ED visits?
Time will be utilized when assigning critical care codes 99291-99292, but NOT for ED E/M codes 99281-99285. The long-standing policy for time in relation to the ED E/M codes has not changed. CPT continues to state, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”
Of note, for 2023, observation services may be reported based on time using the revised Hospital Inpatient and Observation Care Services E/M codes 99221-99223 and 99231-99239.
See the Observation and Critical Care FAQs for additional details regarding documentation of time for those services.
5. What are the modifications to the criteria for determining Medical Decision Making?
6. How is the Medical Decision Making determined?
Within the E/M section of CPT, a grid is used to measure or “score” the Medical Decision Making (MDM). A combination of subcomponents determines the MDM.
E/M |
MDM |
Number and Complexity of Problems Addressed |
Amount and/or Complexity of Data to be Reviewed and Analyzed |
Risk of Complications / Morbidity / Mortality of Patient Management |
99281 |
N/A |
N/A |
N/A |
N/A |
99282 |
Straight Forward |
Minimal |
Minimal or none |
Minimal |
99283 |
Low |
Low |
Limited |
Low |
99284 |
Moderate |
Moderate |
Moderate |
Moderate |
99285 |
High |
High |
Extensive |
High |
7. How are the Number and Complexity of Problem(s) Addressed (COPA) measured?
When assigning a value to the Number and Complexity of Problem(s) Addressed (COPA), there are several factors to consider.
The MDM grid from CPT divides COPA into four levels: Minimal, Low, Moderate, or High.
Number and Complexity of Problems Addressed (COPA) |
|
Minimal |
1 self-limited or minor problem. |
Low |
|
Moderate |
|
High |
|
8. Are there definitions for the bulleted items in the COPA column?
Yes, the E/M guidelines offer these definitions for each of the elements:
9. Are there clinical examples for the bulleted items in the COPA column?
CPT has not published clinical examples for the COPA elements. In addition, the clinical examples for the E/M codes in Appendix C will be deleted from CPT in 2023. The ACEP Coding and Nomenclature Committee has reviewed available CPT guidelines, AMA clarifications published in CPT Assistant, and common practices in the emergency department to offer some guidance when assessing the Complexity of Problems Addressed.
Minimal
Low
"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.
A patient who presents with an illness or injury to be evaluated by the emergency physician does not fit this definition of stable. Additionally, CPT indicates these are “A problem that is new or recent for which treatment has been initiated…” which is unusual in the emergency department setting.
For physicians and coders working in the emergency department, a patient that requires hospitalization seems out of place in the Low COPA category. AMA CPT personnel have said that this bullet was added to provide a mechanism to score Low MDM as required for the inpatient hospital/observation E/M codes. This bullet should not be used when calculating the MDM for patients in the emergency department.
Moderate
In response to a reader’s question, CPT Assistant indicated that abdominal pain would likely represent “at least” Moderate COPA. This could be a patient with chronic abdominal pain, so the presentation would be considered a chronic illness with exacerbation. It may be a patient with no history of abdominal pain that would be an undiagnosed new problem with uncertain prognosis. Or it might present as abdominal pain with vomiting and diarrhea, so it would score as an acute illness with systemic symptoms.
This concept can be applied to many evaluations for patient complaints that should be considered at least Moderate COPA. The following are some examples, but this is not an all-inclusive list:
Abdominal pain |
Psychiatric complaints |
Back pain |
Shortness of breath |
Chest pain |
Systemic rash |
Diarrhea |
Vomiting |
Dizziness |
Weakness |
Headache, Neck pain |
Syncope |
It is important to recognize that all of these presentations exist within a clinical spectrum of severity. At the moderate level, diagnostic evaluations for these would likely involve simple testing, such as plain x-rays or basic lab tests.
High
The final diagnosis for a condition, in and of itself, does not determine the complexity of the MDM. The presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, may indicate that an extensive evaluation is required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
The following high COPA examples may be demonstrated by the totality of the medical record as demonstrated implicitly by the presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, or overall medical decision making, as demonstrated in the entire record.
This is not an all-inclusive list; high COPA should be considered for evaluations of patients with presentations potentially consistent with, but not limited to:
Active labor |
Missed/incomplete abortion |
Ectopic pregnancy |
Ocular emergencies |
Acute intra-abdominal infection or inflammatory process |
Ovarian torsion |
Behavioral health decompensation |
Pulmonary embolism |
Cardiac arrhythmia |
Seizure |
Cardiac ischemia |
Sepsis |
Congestive heart failure |
Sickle cell crisis |
Croup or asthma requiring significant treatment |
Significant blood loss |
CVA, acute neurological change |
Significant complications of pregnancy |
DKA or other significant complications of diabetes |
Significant eye injury |
Endocrine emergencies |
Significant fractures or dislocations |
Epiglottitis |
Significant infection |
Exacerbation of CHF |
Significant metabolic disturbance |
Exacerbation of COPD |
Significant penetrating trauma |
Gastrointestinal obstruction |
Significant vascular disruption, aneurysm, or injury |
Hypertensive crisis |
Solid organ injury |
Intracranial hemorrhage |
Testicular torsion |
Intra-thoracic or intra-abdominal injury due to blunt trauma |
Toxic ingestion |
Kidney stone with potential complications |
It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity.
10. Can I use the R/O or Impressions to determine the Number and Complexity of Problems Addressed at the Encounter?
Yes, physicians may be cautioned against documenting possible, probable, or rule-out diagnoses because these conditions cannot be used for ICD-10 coding in the emergency department, other outpatient settings. However, these rule-out conditions illustrate the significance of the complexity of problems addressed and justify the work done, especially in situations where the final diagnosis seems less than life-threatening. Per CPT:
The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition.
11. Can I use the application of evidence-based risk calculators as an indicator of the complexity of problems addressed?
Yes, the physician/QHP may employ risk stratification tools to ascertain the significance or severity of a presentation and/or help determine appropriate diagnostic or therapeutic interventions. Some tools that may be relevant to emergency medicine are:
Documentation that the physician/QHP used a risk calculator to determine the need for additional testing or treatment is an indicator of the complexity of problems addressed.
When a risk calculator score has suggested that a diagnostic test is not indicated, the Data Category 1 element should be scored the same as if the test had been ordered, as indicated by the CPT statement, “Ordering a test may include those considered but not selected.”
12. Do the comorbidities need to be noted in the MDM, or does mention of them in the HPI or PMH count?
Simply listing the comorbidity does not satisfy the CPT definition. The 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.”
13. How is the Amount and/or Complexity of Data to be Reviewed and Analyzed measured?
Amount and/or Complexity of Data to be Reviewed and Analyzed (Data) is divided into three categories:
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.
Amount and/or Complexity of Data to be Reviewed and Analyzed |
|
Limited – Satisfy at least one category. |
Category 1: Tests and documents At least 2 from the following:
Category 2: Assessment requiring an independent historian(s) |
Moderate – Satisfy at least one category. |
Category 1: Tests, documents, or independent historian(s) At least 3 from the following:
Category 2: Independent interpretation of tests Category 3: Discussion of management or test interpretation |
Extensive – Satisfy at least two categories. |
Category 1: Tests, documents, or independent historian(s) At least 3 from the following:
Category 2: Independent interpretation of tests Category 3: Discussion of management or test interpretation |
14. How do I “score” the bulleted items in Category 1?
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.
15. Is “Assessment requiring an independent historian” Category 1 or Category 2?
It depends on the Data level. For Limited data, it is Category 2; for Moderate and Extensive, it is included in Category 1.
16. What is an independent historian?
17. What qualifies as an independent interpretation of a test for Category 2?
18. Can I count Category 2 for independent interpretation of an EKG when I report 93010?
19. Can I count Category 2 for interpreting a CBC or BMP and documenting “CBC shows mild anemia, no elevated WBC” or “BMP with mild hyponatremia, no hyper K?”
20. If I order a chest x-ray and compare it to a chest x-ray performed six months ago, does this review and comparison constitute an independent interpretation?
Yes, comparing recent x-ray findings to a previous x-ray would be considered an independent interpretation.
21. What qualifies as “discussion” for Category 3 - Discussion of management or test interpretation with external physician/other appropriate source.
22. What is an external physician or another appropriate source for Category 3?
23. How are the Risk of Complications and/or Morbidity or Mortality measured?
The MDM grid in the E/M section of CPT assigns value levels of Risk. For each encounter, patient management decisions made by the physician/QHP are assessed as Minimal, Low, Moderate, or High.
Risk of Complications and/or Morbidity or Mortality of Patient Management |
|
Minimal risk of morbidity from additional diagnostic testing or treatment |
|
Low risk of morbidity from additional diagnostic testing or treatment |
|
Moderate risk of morbidity from additional diagnostic testing or treatment |
Examples only:
|
High risk of morbidity from additional diagnostic testing or treatment |
Examples only:
|
24. Why are there no examples listed for Minimal or Low risk?
There are no published examples of minimal or low risk from diagnostic testing or treatment rendered.
25. What qualifies as prescription drug management in moderate risk?
Prescription drug management is based on documentation that the provider has administered, prescribed, or evaluated current medications during the ED visit. This may be any administration of prescription strength medication while the patient is in the ED, a prescription written to be filled at the pharmacy, discontinuation or modifications to the patient’s existing medication dosages, or after consideration of the current medications, the decision to maintain the current medication regimen.
26. What is the difference between Major and Minor surgery in the risk column?
27. Are there examples of procedures common to the emergency department that would be considered major or minor?
The determination that a procedure is a minor surgery versus a major surgery is at the discretion of the physician/QHP performing the service.
Procedures frequently performed in the ED that may be considered minor surgery may include, but are not limited to:
Procedures frequently performed in the ED that may be considered major surgery may include, but are not limited to:
Note: Some of the major procedure examples are most commonly performed for patients in critical condition. Consider that the E/M service may more appropriately be reported as Critical Care. See the Critical Care FAQs for additional details.
28. What is the difference between elective and emergency surgery in the risk column?
Both elective and emergent procedures may be minor or major procedures.
29. What qualifies as a risk factor for surgery in the risk column?
30. What are social determinants of health (SDOH) that may indicate moderate risk?
Any economic or social condition such as food or housing insecurity that may significantly limit the diagnosis or treatment of a patient’s condition (e.g., inability to afford prescribed medications, unavailability or inaccessibility of healthcare). Common social determinants of health (SDOH) in the emergency department may include homelessness/undomiciled, unemployed, uninsured, and alcohol or polysubstance abuse.
31. Is it sufficient to document the patient’s social determinants of health (SDOH), or must it be listed as a discharge diagnosis? Should the ICD-10 for the social determinants of health (SDOH) be included on the claim?
Diagnosis or treatment of patients in the emergency department may be limited by various social determinants of health identified with an ICD-10 code. ICD-10 groups SDOH into categories, ED relevant SDOH, may include but are not limited to:
The medical record should reflect when the diagnosis or treatment is significantly limited by social determinants of health. However, the SDOH is NOT required to be listed as part of the final diagnosis. The ICD-10 code is NOT required to be coded on the claim.
32. If the patient indicates they are homeless or unemployed at registration, would that count for their social status? Or do I need to include these in my documentation?
33. What is needed to satisfy "Drug therapy requiring intensive monitoring for toxicity?" Has CPT or CMS published examples of qualifying medications?
These are encounters where the patient has been given a medication that has the potential to cause serious morbidity or death and must be monitored for adverse effects.
Monitoring for adverse effects should be a generally accepted practice for the medication and may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify.
CPT has not published a list of “high-risk” medications. The AMA’s position is that trained clinicians understand specific patient and drug factors and know when a medication is high risk depending on the patient situation. CPT expects the physician/QHP to rely on their clinical judgment to determine which medications are at higher risk of morbidity or, in some cases, mortality for a particular patient.
The CMS MAC for Jurisdiction J (Palmetto) has published a list of examples, but many of the meds listed are not typically used in the emergency department. Their list can be found here
The below list is not all-inclusive but provides examples of ED-relevant medications that could cause serious morbidity or death and may be monitored for adverse effects:
Adenosine |
Ketamine |
Amiodarone IV |
Labetalol IV |
Amrinone |
Lidocaine IV |
Atropine |
Magnesium IV |
Bicarbonate IV |
Metoprolol IV |
Blood Products |
Milrinone |
Coumadin |
Nicardipine IV |
D50/Glucagon |
Nitroglycerin IV |
Dexmedetomidine |
Nitroprusside |
Digoxin IV |
Nitrous oxide |
Dilantin (phenytoin) IV |
Norepinephrine |
Diltiazem IV |
Phenylephrine |
Dobutamine |
Potassium IV |
Dopamine |
Precedex (dexmedetodine) |
Droperidol |
Procainamide |
Enalapril IV |
Rocuronium |
Ephedrine |
Propofol |
Epinephrine IV, IM, SQ |
Sodium Nitroprusside |
Esmolol |
Succinylcholine |
Etomidate |
Thrombolytics |
Haldol IV |
Vasopressin |
Heparin |
Versed |
Hydralazine IV |
Verapamil IV |
Insulin IV drip |
3% Normal Saline |
Isoproterenol |
|
34. Does “Decision regarding hospitalization” only apply when the patient is admitted to the hospital or observation?
Decision regarding hospitalization involves consideration of an escalation of care beyond the ED, such as Observation or Inpatient status. Additionally, the determination of risk also includes decision making when the outcome is to forego further testing, treatment, and/or hospitalization. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision not to hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.
35. Which medications qualify as parenteral controlled substances in the high section of the risk column?
This list is not all-inclusive, but ED-relevant parenteral controlled substances may include:
· Buprenorphine (Suboxone) |
· Morphine |
· Diazepam (Valium) |
· Naloxone (Narcan) |
· Fentanyl (Sublimaze, Duragesic) |
· Nubain (nalbuphine) |
· Hydromorphone (Dilaudid) |
· Pentobarbital |
· Ketamine |
· Phenobarbital |
· Lorazepam (Ativan) |
· Stadol (butorphanol) |
· Meperidine (Demerol) |
· Sufentanil |
· Methadone (Dolophine) |
· Talwin (pentazocine) |
· Methohexital |
· Thiopental |
· Midazolam (Versed) |
· Versed (midazolam) |
36. 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?
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
37. Do these guidelines apply to the observation E/M codes also?
Yes, observation services will now use the MDM guidelines detailed above, or observation E/M codes can be assigned based on the physician’s total time on the date of the encounter.
However, the Initial Observation Care codes 99218, 99219, and 99220, Subsequent Observation Care codes 99224, 99225, 99226, and Observation Discharge code 99217 have all been deleted for 2023.
The inpatient E&M codes 99221-99223, and 99231-99239, have been revised to Hospital Inpatient and Observation Care Services.
See the Physician Observation FAQ for more information.
38. We use the Office E/M codes 99202-99215 to report our services in the Urgent Care Center. Do these revisions apply to those codes as well?
The Office or Other Outpatient E/M codes 99202-99215 have been using the revised E/M guidelines since January 2021. E/M codes 99202-99215 are assigned based on medical decision making or Time. The MDM is determined by the same MDM grid as detailed above. The revised code descriptors indicate the time required for each level of service.
An Urgent Care E/M FAQ will be available soon.
39. Where can I find the complete set of guidelines?
They can be found in the Evaluation and Management (E/M) Services Guidelines section of the 2023 CPT Manual. They can be downloaded here.
40. Where can I download a copy of the 2023 MDM Grid?
The only official source for the MDM grid is the 2023 CPT book. A modified version of the grid to specifically address the ED E/M codes can be downloaded here.
Last Updated: October 2022
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