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October 13, 2022

Major Documentation Changes are Coming in 2023—Got Questions? ACEP’s Got Answers

As many of you probably know, the American Medical Association (AMA) has released Current Procedural Terminology (CPT) documentation guideline changes for all evaluation and management (E/M) services. While the guideline changes began applying to the office and outpatient E/M services in 2021, they will kick into effect for other E/M services, including emergency department (ED) E/M services, starting in 2023.

I don’t need to tell you how big a deal this is (but I will anyways!). These documentation guidelines help determine what level of ED E/M service you as emergency physicians should pick for a given ED visit. The ED E/M codes are the “bread and butter” of codes that you bill (85 percent of the time!). Thus, any change to the guidelines not only affects (obviously) how you go about documenting a visit, but also could have a significant impact on your revenue.

This is truly a once-in-a-generation occurrence, as these guidelines haven’t been updated since the 1990s. And just as with other policy changes that impact emergency physicians, ACEP has been at the forefront of helping not only to shape the modifications themselves, but also to help the emergency medicine community understand them all.

First, from an advocacy perspective, ACEP had a voice in the CPT and Relative Value Scale (RVS) Update Committee (RUC) decision making processes when these documentation guideline changes were being discussed. We were able to successfully convince a Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service. As I have stated before, it is nearly impossible to measure the time a service takes to complete in the ED. Further, the time spent with a patient in the ED does not necessarily dictate the intensity of the service being delivered.

ACEP was also able to ensure that all five levels of the ED E/M services (levels 1-5, CPT codes 99281-99285) remained untouched. In other words, even though there are changes to how you document each ED E/M service, the actual codes are the same. Eliminating or combining certain codes could have had even more of an impact (and perhaps a deleterious one) on your overall reimbursement.

Now, on to the efforts ACEP has taken to educate our members about the changes. Soon after the documentation guideline changes were released, ACEP offered a special briefing web conference on July 12, 2022. That four-and-a-half-hour conference featured an in-depth review of the 2023 changes with special emphasis on both physician documentation requirements and coder training for extracting those elements, along with real-world emergency department case studies to illustrate that content. David McKenzie, ACEP’s Reimbursement Director, and ACEP member Michael A. Granovsky, MD, FACEP, CPC, also wrote an ACEPNow article in September highlighting the major changes and what they mean for you.

However, we have heard a lot of feedback from many of you that you need additional information about exactly what changes are being made. I am happy to announce that last week, ACEP published a comprehensive set of frequently asked questions (FAQs) that were developed by billing and coding experts within ACEP’s Coding and Nomenclature Advisory Committee (CNAC).

While I won’t ruin all the fun you will have reviewing these FAQs, I do want to mention some key points:

  • The most significant revision to the 2023 E/M guidelines is the elimination of history and physical exam as elements for ED E/M code selection. Beginning in 2023, the ED E/M services will be based only on medical decision making (MDM).
    • It is important to note that while history and exam will no longer directly contribute to selecting the E/M code, the ED E/M codes stipulate that there should be a medically appropriate history and/or physical examination.
  • There are modifications to the criteria for determining the level of MDM, as explained in FAQ #5. Interestingly, the final diagnosis will not be 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. This helps reinforce the concept of the prudent layperson standard.
  • FAQ #6 lays out a grid to use to measure MDM and understand what code to bill. MDM is broken out into three categories: 1) Number and Complexity of Problems Addressed; 2) Amount and/or Complexity of Data to be Reviewed and Analyzed; and 3) Risk of Complications / Morbidity / Mortality of Patient Management. Based on those three MDM factors, you can pick a level 1 (no MDM), level 2 (straight forward MDM), level 3 (low MDM), level 4 (moderate MDM), or level 5 (high MDM) service.
  • Most of the remaining FAQs explain these three categories in detail and include numerous clinical scenarios that will help you determine the appropriate MDM level within each category.
    • Number And Complexity of Problems Addressed: The most significant change here is that there is no longer a major distinction made for additional workup planned and no longer points for a new problem to the examiner.
    • Amount and/or Complexity of Data to be Reviewed and Analyzed: This component has the most changes in clarifications including scoring for ordering or reviewing each unique test.
    • Risk of Complications and/or Morbidity or Mortality of Patient Management: This is still based on the previous “table of risk” with the highest element of risk prevailing for the level assigned. It is important to note that social risk factors, such as homelessness and food insecurity, count as “moderate risk.” This is the first time that social risk factors have impacted the level of service that you as emergency physicians will bill.
  • Finally, another major change, highlighted in FAQ #36, is that you can get MDM credit for the decision making process regarding whether to initiate or forego further testing, treatment, and/or hospitalization/escalation. In other words, even if you ultimately decide not to order a test, treatment, or management option, the consideration of such an action or service can contribute to the complexity of the medical decision.

We hope that the FAQs are helpful, and I encourage you to review them all. Once you do, please let us know if they answer your questions—or if there are other questions you have that you think we should add to the FAQ set. You are welcome to contact me directly (jdavis@acep.org) or ACEP’s Reimbursement Director, David McKenzie (dmckenzie@acep.org). These FAQs will continue to evolve, especially after the release of the Calendar Year 2023 Medicare Physician Fee Schedule final regulation on or about November 1, 2022. However, we know you all need this information as soon as possible to prepare for the upcoming changes.

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.

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