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2023 Emergency Department Evaluation and Management Guidelines

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.

  • 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.

2. How do the new guidelines differ from the existing guidelines?

The most significant revisions to the 2023 E/M Guidelines are:

  • 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.
    • Note that time is NOT used to select ED E/M levels of service. (See FAQ #4)
  • Revisions to the rules for using Time to assign an E/M code.
  • Modifications to the criteria for determining the level of Medical Decision Making (MDM).

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?

  • There are minor changes to the three current MDM subcomponents, but there have been extensive edits to the process of “scoring” MDM elements for code selection.
  • The current CMS Table of Risk and Contractor audit tools were used as a basis for designing the revised required elements for MDM.
  • The revisions removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
  • AMA has provided definitions for important terms, such as “Independent historian,” “other appropriate source,” etc.
  • The Marshfield MDM scoring is no longer a factor; the long-standing debate of new problem vs. established problem and no additional workup vs. additional workup planned have been eliminated.
  • Changes in scoring Complexity of Data Reviewed include points counted for each unique test ordered/reviewed, review of prior external notes, and history from an independent historian.
  • 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.
  • 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 to identify or rule out a highly morbid condition will determine MDM even when the ultimate diagnosis is not highly morbid.

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.

  • The number and complexity of problem(s) addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed.
  • 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).
  • The Level of MDM is based on 2 out of 3 elements being met.

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 problem has been addressed when it is evaluated or treated by the physician/QHP, with or without a diagnosis established during the encounter.
  • 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.

 

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

  • 2 or more self-limited or minor problems
  • 1 stable chronic illness
  • 1 acute, uncomplicated illness or injury
  • 1 stable, acute illness
  • 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care

Moderate

  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment.
  • 2 or more stable chronic illnesses.
  • 1 undiagnosed new problem with uncertain prognosis.
  • 1 acute illness with systemic symptoms.
  • 1 acute complicated injury

High

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment.
  • 1 acute or chronic illness or injury that poses a threat to life or bodily function

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:

  • Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
  • Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether stage or severity changes (e.g., uncontrolled diabetes and controlled diabetes are a single chronic condition).
    • "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.
      • For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
    • Acute, uncomplicated illness or injury: A recent or new short-term problem with a low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.
      • A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
    • Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
    • Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
    • Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.
    • Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
    • Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment.
      • Systemic symptoms may not be general but may affect a single system.
      • For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury.
    • Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.
    • Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in the level of care.
    • Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment that poses a threat to life or bodily function in the near term without treatment.
      • Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential

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

  • 1 self-limited or minor problem.
    • It is improbable that many patients that present to the emergency department clinically fit into this category. CPT stipulates that a problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Given this description, an illness or injury that warrants a visit to the emergency room seems to exceed what would be considered a self-limited or minor problem. Presentations in this category will most likely be limited to patients who return to the ED for uncomplicated suture removal, dressing changes, or packing removal.

Low          

  • 2 or more self-limited or minor problems
    • See the above description of a self-limited or minor problem.
  • 1 stable chronic illness and
  • 1 stable, acute illness
    • The CPT definition of “Stable” makes it doubtful that patients presenting to the department fit into these categories.

"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.

  • Acute, uncomplicated illness or injury
    • ED presentations in this category will be limited to localized complaints that do not include additional signs or symptoms.
    • Uncomplicated injuries will be minor traumatic injuries that are appropriately evaluated without x-rays (e.g., extremity injuries with limited pain, swelling, or bruising) and can usually be managed with over-the-counter medications. Injuries that require prescription medications for more aggressive pain management or other prescription medications (e.g., antibiotics due to infection risk) are typically more consistent with an acute complicated injury.
    • Uncomplicated illnesses are minor illnesses with no associated systemic symptoms and can be evaluated without testing or imaging (e.g., isolated URI symptoms). Most of these patients can be reasonably treated with over-the-counter medications.  Illnesses that have developed associated signs or symptoms, or require testing or imaging, or necessitate treatment with prescription strength medications have progressed beyond an uncomplicated illness.
    • 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care

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      

  • 2 or more stable chronic illnesses.
    • See the above explanation of stable chronic illness.
  • 1 acute complicated injury
    • As indicated by the CPT definition, these are injuries that require an evaluation of organ systems or body areas beyond just the injury site (e.g., musculoskeletal injuries where an assessment of distal neurovascular function is indicated).
    • A patient’s mechanism of injury can also be an indication of an acute complicated injury. ED presentations prompted by a fall, MVA, fight, bicycle accident, or any other accident require the physician/QHP to evaluate multiple organ systems or body areas to identify or rule out injuries.
    • Accidents and/or injuries that necessitate diagnostic imaging to rule out significant clinical conditions such as fracture, dislocation, or foreign bodies are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity.
  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment.
    • Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
      • chronic illnesses with exacerbation, OR
      • chronic illnesses with progression, OR
      • chronic illnesses with side effects of treatment.
    • 1 undiagnosed new problem with uncertain prognosis.
    • 1 acute illness with systemic symptoms.
      • There are many presenting problems, chief complaints, and associated signs and symptoms that could fit into these three categories.

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. 

  • Systemic symptoms may involve a single system or more than one system. Presentations representing two or more systems seem to exceed a single acute uncomplicated illness or injury, suggesting at least a moderate COPA. CPT states, “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
  • Fever is generally considered to likely represent a systemic response to an illness. CPT states that fever associated with a minor illness that may be treated to alleviate symptoms is more typical of an uncomplicated illness. For example, an otherwise healthy patient with a fever solely associated with uncomplicated viral URI symptoms is a less concerning clinical process. However, fever or body aches not associated with a minor illness or associated with illnesses requiring diagnostic testing or prescription drug management may represent a broader complexity of problem being addressed or treated.
  • Regardless of final diagnosis, accidents and/or injuries that necessitate diagnostic imaging to identify or rule out a clinical condition such as a fracture, a dislocation, or a foreign body are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity and consistent with an undiagnosed new problem with uncertain prognosis.
  • The physician/QHP ordering and/or reviewing extensive labs and/or complex imaging and/or consulting with a specialist indicates an investigation to evaluate for broader concerns with more complex clinical considerations. This would suggest that the encounter has exceeded what would reasonably be considered moderate COPA.

High

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
    • Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
      • chronic illnesses with severe exacerbation, OR
      • chronic illnesses with severe progression, OR
      • chronic illnesses with severe side effects of treatment.
  • 1 acute or chronic illness or injury that poses a threat to life or bodily function
    • Presenting problems in these High COPA categories are high-risk presentations where the physician/QHP is evaluating or ruling out a condition with a significant risk of morbidity or one that poses a threat to life or bodily function. These are patients with symptoms that potentially represent a highly morbid condition and therefore support high MDM even when the ultimate diagnosis is not highly morbid.   

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:

  • Canadian CT Head Injury rule – Calculates the need for a CT for patients with a head injury.
  • HEART score – for major cardiac events and to determine between discharge or admit/obs from the ED
  • NEXUS and Canadian c-spine rule to out potentially disabling c-spine injury.
  • Ottawa Ankle and Knee Rule - Calculates the need for an x-ray for patients with an ankle/knee injury.
  • PECARN for Pediatric Head Injury - Predicts need for brain imaging after pediatric head injury.
  • PERC Rule For Pulmonary Embolism - Rules out PE if no criteria are present and pre-test probability is ≤15%.
  • Pneumonia Severity Index / PORT score – Estimates mortality for adult patients with community-acquired pneumonia and determines between discharge or admit/obs from the ED
  • Well’s Criteria for DVT - Calculates risk of DVT based on clinical criteria
  • Well’s Criteria for Pulmonary Embolism - Objectifies risk of pulmonary embolism.

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:

  • Category 1: Tests, documents, orders, or independent historian(s).
  • Category 2: Independent interpretation of tests (not separately reported).
  • 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.    

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:

  • Review of prior external note(s) from each unique source; (each note counts as 1)
  • Review of the result(s) of each unique test; (each test counts as 1)
  • Ordering of each unique test (each test counts as 1)

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:

  • Review of prior external note(s) from each unique source; (each note counts as 1)
  • Review of the result(s) of each unique test; (each test counts as 1)
  • Ordering of each unique test (each test counts as 1)
  • Assessment requiring an independent historian(s)

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:

  • Review of prior external note(s) from each unique source; (each note counts as 1)
  • Review of the result(s) of each unique test; (each test counts as 1)
  • Ordering of each unique test (each test counts as 1)
  • Assessment requiring an independent historian(s) 

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.

  • 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 the emergency physicians, these will be any notes that come from outside their 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.
    • A lab test ordered, plus an external note reviewed and an independent historian would be a total of three for Category 1 under moderate or extensive data.
    • All the Category 1 value can come from a single bulleted element.
    • Ordering an EKG (93010), a CBC (85027), and a CMP (80053) is a total of three for Category 1, even though they are all from the same element (Ordering of each unique test).
    • Ordering a CBC, CMP, and cardiac troponin is a total of three for Category 1, even though they are all lab tests, as each test has a unique CPT code.

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?

  • Any individual (e.g., EMS, parent, caregiver, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient.
  • The independent historian should provide additional information and not merely restate information already been provided by the patient unless confirmation is necessary.
  • The physician/QHP may query an independent historian when the patient is unable to provide a complete or reliable history for any reason, e.g., developmental stage, mental status, clinical urgency.
  • The physician/QHP may query an independent historian when a confirmatory history is judged to be necessary.
  • In cases in which the patient cannot provide any information (e.g., developmental age), the independent historian may provide all of the required information.
  • The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
  • Independent historian does not include translation services.

17. What qualifies as an independent interpretation of a test for Category 2?

  • Any interpretation of a test for which there is a CPT code, and an interpretation or report is customary.
  • In the emergency department, examples include X-ray, EKG, ultrasound, CT scan, and rhythm strip interpretations.
  • A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
  • If the CPT code for the independent interpretation is separately reported, it cannot also be counted in Category 2.

18. Can I count Category 2 for independent interpretation of an EKG when I report 93010?

  • 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.”

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?”

  • No, Category 2 only applies for interpreting a test where an interpretation or report is customary, e.g., EKG, X-ray, ultrasound, rhythm strip. Lab tests do not have a separate interpretation component.
  • Per CPT, “Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.”

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.

  • Discussion requires an interactive exchange.
  • The exchange must be direct and not through nonclinical intermediaries.
  • Sending chart notes or written exchanges within progress notes do not qualify as an interactive exchange.
  • It may be asynchronous; it does not need to be in person.

22. What is an external physician or another appropriate source for Category 3?

  • Any external physician/QHP who is not in the same group practice or is of a different specialty or subspecialty within the same group.
  • It may also be the staff of a facility or organizational provider such as a hospital, nursing facility, or home health care agency.
  • An appropriate source are professionals who are not health care professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher).
  • Appropriate source does not include discussion with family or informal caregivers.

23. How are the Risk of Complications and/or Morbidity or Mortality measured?

  • The assessment of the level of risk is affected by the nature of the event under consideration.
  • 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. They do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).
  • For the purpose of MDM, the level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.
  • 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.
  • Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.

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:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors.
  • Diagnosis or treatment significantly limited by social determinants of health

High risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization or escalation of hospital-level of care
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
  • Parenteral controlled substances

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?

  • The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians.
  • These terms are not defined by a surgical package classification.

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:

  • 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:

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

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?

  • An elective procedure is typically planned in advance, e.g., scheduled for weeks later.
  • An emergent procedure is typically performed immediately or with minimal delay.

Both elective and emergent procedures may be minor or major procedures.

29. What qualifies as a risk factor for surgery in the risk column?

  • Risk factors associated with a procedure may be specific to the procedure or specific to the patient.
  • An otherwise low-risk procedure on a patient with an underlying condition that increases the risk of a poor outcome could be considered moderate or even high risk.
  • The physician/QHP may use evidence-based risk calculators when assessing patient and procedure risk, but it is not required. (see question 11 for examples of ED-relevant risk calculators)

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:

  • Problems related to education and literacy, e.g., Z55.0 - Illiteracy and low-level literacy
  • Problems related to employment and unemployment, e.g., Z56.0 - Unemployment, unspecified
  • Occupational exposure to risk factors, e.g., Z57.6 - Occupational exposure to extreme temperature
  • Problems related to housing and economic circumstances, e.g., Z59.0 - Homelessness or Z59.6 - Low income
  • Problems related to social environment, e.g., Z60.2 - Problems related to living alone
  • Problems related to upbringing, e.g., Z62.0 - Inadequate parental supervision and control
  • Other problems related to primary support group, including family circumstances, e.g., Z63.0 - Problems in relationship with spouse or partner

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?

  • The mere presence of an issue is not the determining factor.
  • The risk table stipulates, “Diagnosis or treatment significantly limited by social determinants of health.”
  • The documentation should indicate how the SDOH was relevant to the diagnosis and treatment of the patient through one of the mechanisms addressed above.

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 https://www.palmettogba.com/palmetto/jjb.nsf/DID/8EELEJ7715

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

·       Coumadin

·       Milrinone

·       D50/Glucagon

·       Nicardipine IV

·       Dexmedetomidine

·       Nitroglycerin IV

·       Digoxin IV

·       Nitroprusside

·       Dilantin (phenytoin) IV

·       Nitrous oxide

·       Diltiazem IV

·       Norepinephrine

·       Dobutamine

·       Phenylephrine

·       Dopamine

·       Potassium IV

·       Droperidol

·       Precedex (dexmedetodine)

·       Enalapril IV

·       Procainamide

·       Ephedrine

·       Rocuronium

·       Epinephrine IV, IM, SQ

·       Propofol

·       Esmolol

·       Sodium Nitroprusside

·       Etomidate

·       Succinylcholine

·       Haldol IV

·       Thrombolytics

·       Heparin

·       Vasopressin

·       Hydralazine IV

·       Versed

·       Insulin IV drip

·       Verapamil IV

·       Isoproterenol

·       3% Normal Saline

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?

  • It is not just the medication; it is the route of administration plus the medication.
  • Parenteral, administered by means other than the alimentary tract.
  • Controlled Substance – a schedule I, II, III, IV, or V drug or other substance.

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

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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