This guide addresses frequently asked questions regarding the 2023 updates to the Evaluation and Management (E/M) coding guidelines, specifically for emergency department services. These revisions aim to simplify and clarify the coding process, primarily focusing on Medical Decision Making (MDM) as the key determinant for code selection.
1. 2023 E/M Code Updates for Emergency Physician Services
Question: Are there new E/M codes to report emergency physician services for 2023?
Answer: While the codes themselves (99281-99285) remain unchanged, the code descriptors have been significantly revised. These revisions, stemming from the AMA’s updates to office visit E/M codes in 2019, and further extensions to other E/M sections including Emergency Department codes released in July 2022, are designed to bring uniformity across all E/M coding sections. Effective January 1, 2023, these revised guidelines apply to all E/M codes.
For Emergency Department E/M, the key update is the alignment with the revised E/M coding philosophy where code selection is now primarily based on Medical Decision Making (MDM).
Here’s a breakdown of the 2023 Emergency Department E/M code descriptors:
- 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. Key Differences Between 2023 and 1995 E/M Guidelines
Question: How do the 2023 E/M Guidelines differ from the 1995 E/M Documentation Guidelines?
Answer: The 2023 E/M Guidelines introduce several significant changes compared to the 1995 guidelines:
- Elimination of History and Physical Exam as Code Selection Factors: History and physical exam are no longer direct elements for determining the E/M code level.
- MDM or Time-Based Code Selection: E/M code selection is primarily based on Medical Decision Making (MDM) or, in some sections, Total Time. However, it’s crucial to note that time is NOT a factor for selecting ED E/M levels of service.
- Revised Time-Based Rules: While not applicable to ED E/M, the rules for using Time in other E/M sections have been modified.
- Modifications to MDM Criteria: The criteria for determining the level of Medical Decision Making (MDM) have been significantly revised.
3. The Role of History and Exam in 2023 E/M Coding
Question: Do these changes mean I am no longer required to document a history or exam?
Answer: No. While history and physical exam are not direct factors in E/M code selection, the Emergency Department E/M codes explicitly state that a medically appropriate history and/or physical examination is required.
The physician or Qualified Healthcare Professional (QHP) determines the scope and nature of the history and physical exam based on clinical judgment. It is important to understand that the extent of documented history and physical exam does not dictate the E/M code assignment.
However, detailed history and exam documentation remain vital for accurately reflecting the complexity of the patient’s problems and supporting the assigned MDM level. The MDM framework utilizes descriptors like “acute, uncomplicated illness or injury,” “undiagnosed new problem with uncertain prognosis,” and “acute illness with systemic symptoms.” A comprehensive history and exam provide the necessary context for coders and auditors to understand the complexity and justify the assigned MDM level.
4. Documenting Past, Family, and Social History
Question: Do I still need to document or import the patient’s entire past, family, and social history from nurse’s notes or prior medical records?
Answer: Only document past, family, and social history when it is clinically relevant to the current Emergency Department service. The AMA/CPT encourages reducing “note bloat” caused by automatically importing data from EHR templates that adds little clinical value. Focus on documenting pertinent information that directly impacts the current encounter’s medical decision making.
5. Time Documentation for ED Visits
Question: If E/M codes are selected based on Medical Decision Making or Total Time, do I need to document my time for ED visits?
Answer: No, time is not a factor in determining the level of service for Emergency Department E/M codes (99281-99285). Code selection is exclusively based on the level of Medical Decision Making (MDM). Therefore, documenting time spent on ED visits is not required for code selection under the 2023 guidelines.
6. Modifications to Medical Decision Making (MDM) Criteria
Question: What are the modifications to the criteria for determining Medical Decision Making?
Answer: The 2023 E/M guideline revisions include minor adjustments to the three MDM sub-components but significant changes to the process of “scoring” MDM elements for code selection.
Key modifications to MDM criteria include:
- CMS Table of Risk and Audit Tools Influence: The revised MDM elements are based on the current CMS Table of Risk and contractor audit tools.
- Clarity and Definition: Ambiguous terms like “mild” have been removed, and previously unclear concepts such as “acute or chronic illness with systemic symptoms” are now defined.
- AMA Definitions: The AMA provides definitions for essential terms like “Independent historian” and “other appropriate source.”
- Marshfield MDM Scoring Eliminated: The Marshfield MDM scoring system is no longer relevant. The debates surrounding “new vs. established problem” and “additional workup planned vs. no additional workup” have been removed.
- Changes in Data Complexity Scoring: Scoring for the Complexity of Data Reviewed now includes points for each unique test ordered/reviewed, review of prior external notes, and history from an independent historian.
- Cognitive Effort Recognition: The cognitive effort involved in considering tests or treatments that are not performed is now acknowledged as contributing to MDM complexity.
- Risk vs. Benefit of Hospital Admission: Assessing the risk versus benefit of hospital admission is recognized as a high-risk decision, even if the patient is ultimately discharged or sent to alternative care settings.
- Final Diagnosis Not Sole Determinant: The final diagnosis is not the only factor in determining the E/M code. Presenting symptoms suggestive of a highly morbid condition requiring extensive evaluation can drive MDM, even if the final diagnosis is less severe.
7. Determining Medical Decision Making (MDM) Level
Question: How is Medical Decision Making determined?
Answer: Medical Decision Making (MDM) is determined by assessing three components:
- Number and Complexity of Problems Addressed
- Amount and/or Complexity of Data to be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality of Patient Management
The table below outlines the MDM level corresponding to each E/M code (99281-99285):
| E/M Code | MDM Level | 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 | Straightforward | Minimal | Minimal or none | Minimal |
| 99283 | Low | Low | Limited | Low |
| 99284 | Moderate | Moderate | Moderate | Moderate |
| 99285 | High | High | Extensive | High |
8. Measuring Number and Complexity of Problems Addressed (COPA)
Question: How are the Number and Complexity of Problem(s) Addressed (COPA) measured?
Answer: When evaluating the Number and Complexity of Problem(s) Addressed (COPA), consider these factors:
- Problem Evaluation or Treatment: A problem is considered “addressed” when it is evaluated or treated by the physician/QHP, regardless of whether a definitive diagnosis is established during the encounter.
- Consideration of Further Action: This includes contemplating further testing or treatment that might not be performed due to risk-benefit analysis or patient/guardian choice.
- Multiple Problems: Multiple minor illnesses or injuries, when combined, can increase MDM complexity.
- Comorbidities: Comorbidities and underlying diseases contribute to MDM if addressed during the encounter.
- Aggregate Complexity: Multiple lower severity problems can collectively create higher complexity.
- Final Diagnosis vs. Evaluation Extent: The final diagnosis does not solely determine complexity or risk. Extensive evaluation to rule out a highly morbid condition can drive MDM.
- Presenting Symptoms Importance: Presenting symptoms suggestive of a potentially serious condition can “drive” MDM even if the ultimate diagnosis is less severe.
The MDM grid categorizes 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 |
9. Definitions of COPA Elements
Question: Are there definitions for the bulleted items in the COPA column?
Answer: Yes, the E/M guidelines provide definitions for each element in the COPA column:
- Self-limited or minor problem: A problem that runs a defined course, is temporary, and is unlikely to cause lasting health changes.
- Stable, chronic illness: A problem lasting at least a year or until death. Chronicity applies regardless of stage or severity changes (e.g., controlled or uncontrolled diabetes is a single chronic condition).
- “Stable” means the patient is meeting their specific treatment goals. A patient not at their treatment goal is not stable, even without immediate life threat. Example: persistently poorly controlled blood pressure is unstable even if asymptomatic.
- Acute, uncomplicated illness or injury: A recent, short-term problem with low morbidity risk, for which treatment is considered. Full recovery without impairment is expected. A normally self-limited problem that isn’t resolving as expected is also considered acute, uncomplicated.
- Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: Similar to above, but requiring hospital-level treatment. Full recovery expected.
- Stable, acute illness: A new or recent problem with initiated treatment. Patient is improved and stable concerning this condition, though not fully resolved.
- Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness worsening, poorly controlled, progressing, requiring more supportive care, or attention to treatment side effects.
- Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis likely to cause high morbidity without treatment.
- Morbidity: Illness or impairment expected to be of substantial duration, limiting function, impairing quality of life, or causing potentially non-transient organ damage.
- Acute illness with systemic symptoms: An illness causing systemic symptoms with high morbidity risk if untreated. Systemic symptoms may affect a single system or be general. For minor illness with general symptoms treatable for symptom relief, see “self-limited or minor problem” or “acute, uncomplicated illness or injury.”
- Acute, complicated injury: An injury requiring evaluation of body systems beyond the injured area, is extensive, or treatment options are multiple and/or risky.
- Chronic illness with severe exacerbation, progression, or side effects of treatment: Severe worsening or progression of a chronic illness or severe treatment side effects with significant morbidity risk, possibly requiring escalated care.
- Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, acute complicated injury, or chronic illness/injury exacerbation/progression/side effects posing a near-term threat to life or bodily function without treatment. Symptoms potentially representing a significant threat can also fall into this category if evaluation and treatment align with this potential severity.
10. Clinical Examples for COPA Elements
Question: Are there clinical examples for the bulleted items in the COPA column?
Answer: The CPT manual itself does not provide clinical examples for COPA elements, and Appendix C clinical examples for E/M codes were removed in 2023. However, the ACEP Coding and Nomenclature Committee has offered guidance based on CPT guidelines, AMA clarifications in CPT Assistant, and common emergency department practices.
Minimal COPA
- One self-limited or minor problem: It’s unlikely many ED presentations fit this category. CPT clarifies that a normally self-limited problem not resolving as expected becomes an acute, uncomplicated illness. True minimal presentations are mostly limited to uncomplicated suture removal, dressing changes, or packing removal.
Low COPA
- Two or more self-limited or minor problems: (See above description).
- One stable chronic illness and One stable, acute illness: The CPT definition of “stable” makes it doubtful ED patients fit these categories. “Stable” is defined by meeting treatment goals, which is unlikely for a patient presenting for ED evaluation. Also, CPT defines these as “A problem that is new or recent for which treatment has been initiated…”, unusual in the ED.
- Acute, uncomplicated illness or injury: ED presentations are limited to localized complaints without systemic signs/symptoms. Uncomplicated injuries are minor traumatic injuries evaluated without x-rays (e.g., limited pain extremity injuries managed with OTC meds). Injuries needing prescription pain management or antibiotics are usually more complex. Uncomplicated illnesses are minor, without systemic symptoms, evaluated without tests/imaging (e.g., isolated URI symptoms), and treatable with OTC medications. Illnesses with associated signs/symptoms, needing tests/imaging, or prescription medications are beyond uncomplicated.
- One acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care: For ED coding, hospital admission for a “low” complexity problem seems misplaced. CPT personnel clarified this bullet was added to score Low MDM for inpatient/observation E/M codes and should not be used for ED MDM calculation.
Moderate COPA
- Two or more stable chronic illnesses: (See above explanation of stable chronic illness).
- One acute complicated injury: Injuries needing evaluation beyond the injury site (e.g., musculoskeletal injuries needing distal neurovascular assessment). Mechanism of injury also indicates complexity (falls, MVAs, accidents require multi-system evaluation). Injuries needing imaging to rule out significant conditions (fractures, dislocations) are complex with multiple treatment options and morbidity risk.
- One or more chronic illnesses with exacerbation, progression, or side effects of treatment: Interpreted as: chronic illnesses with exacerbation, OR progression, OR side effects.
- One undiagnosed new problem with uncertain prognosis.
- One acute illness with systemic symptoms.
CPT Assistant indicated abdominal pain is “at least” Moderate COPA, potentially fitting “chronic illness with exacerbation,” “undiagnosed new problem,” or “acute illness with systemic symptoms” (if with vomiting/diarrhea).
This “at least Moderate COPA” concept applies to many common ED complaints (not all-inclusive):
| Abdominal pain | Psychiatric complaints |
|---|---|
| Back pain | Shortness of breath |
| Chest pain | Systemic rash |
| Diarrhea | Vomiting |
| Dizziness | Weakness |
| Headache, Neck pain | Syncope |
Severity exists on a spectrum. Moderate level evaluations involve simple tests like plain x-rays or basic labs.
- Systemic symptoms can involve one or more systems. Multi-system presentations exceed a single acute uncomplicated illness, suggesting at least moderate COPA. CPT: “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
- Fever can indicate a systemic response. Fever with minor viral URI symptoms in an otherwise healthy patient is uncomplicated. Fever/body aches not with minor illness or needing tests/prescription drugs suggest broader problem complexity.
- Accidents/injuries needing imaging to rule out fracture, dislocation, foreign bodies indicate extensive injury, multiple treatments, morbidity risk, and are consistent with “undiagnosed new problem with uncertain prognosis.”
- Ordering advanced labs or complex imaging (Troponin, CT, MRI) or consultation/escalation suggests consideration of a condition posing a life or bodily function threat, likely surpassing moderate COPA.
High COPA
- One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment: Interpreted as: chronic illnesses with severe exacerbation, OR severe progression, OR severe side effects.
- One acute or chronic illness or injury that poses a threat to life or bodily function: High-risk presentations where a condition with significant morbidity risk or life/function threat is being evaluated/ruled out. Symptoms suggesting a highly morbid condition support high MDM even if the final diagnosis is less severe.
Final diagnosis alone doesn’t determine MDM complexity. Presenting problem, diagnostic evaluation, treatment, management, or differential diagnoses may indicate extensive evaluation is needed to conclude symptoms are not highly morbid.
High COPA examples (not all-inclusive), implicitly demonstrated by presenting problem, evaluation, treatment, management, differential diagnoses, or overall MDM:
| Active labor | Missed/incomplete abortion |
|---|---|
| Ectopic pregnancy | Ocular emergencies |
| Acute intra-abdominal infection/inflammation | Ovarian torsion |
| Behavioral health decompensation | Pulmonary embolism |
| Cardiac arrhythmia | Seizure |
| Cardiac ischemia | Sepsis |
| Congestive heart failure | Sickle cell crisis |
| Croup/asthma requiring significant treatment | Significant blood loss |
| CVA, acute neurological change | Significant complications of pregnancy |
| DKA, diabetes complications | Significant eye injury |
| Endocrine emergencies | Significant fractures/dislocations |
| Epiglottitis | Significant infection |
| Exacerbation of CHF | Significant metabolic disturbance |
| Exacerbation of COPD | Significant penetrating trauma |
| Gastrointestinal obstruction | Significant vascular disruption/aneurysm/injury |
| Hypertensive crisis | Solid organ injury |
| Intracranial hemorrhage | Testicular torsion |
| Intra-thoracic/abdominal blunt trauma injury | Toxic ingestion |
| Kidney stone with potential complications |
Listing these conditions as the final diagnosis is unnecessary. Extensive evaluation to rule out these or any condition posing a life/function threat indicates High COPA if evaluation/treatment aligns with this potential severity.
11. Using Rule-Out (R/O) or Impressions for COPA
Question: Can I use the R/O or Impressions to determine the Number and Complexity of Problems Addressed at the Encounter?
Answer: Yes. While physicians are often cautioned against documenting “possible,” “probable,” or “rule-out” diagnoses for ICD-10 coding in the ED and outpatient settings, these rule-out conditions do illustrate the significance of problem complexity and justify the work performed, especially when the final diagnosis seems less severe.
CPT states: “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.”
12. Risk Calculators and COPA
Question: Can I use the application of evidence-based risk calculators as an indicator of the complexity of problems addressed?
Answer: Yes, risk stratification tools can help determine presentation significance/severity and guide diagnostic/therapeutic interventions. Relevant ED tools include:
- Canadian CT Head Injury rule
- HEART score (cardiac events)
- NEXUS and Canadian c-spine rule
- Ottawa Ankle and Knee Rule
- PECARN (Pediatric Head Injury)
- PERC Rule (Pulmonary Embolism)
- Pneumonia Severity Index / PORT score
- Well’s Criteria for DVT
- Well’s Criteria for Pulmonary Embolism
Documenting risk calculator use to determine testing/treatment indicates problem complexity.
If a risk calculator suggests a test isn’t indicated, Data Category 1 should be scored as if the test was ordered, as CPT states, “Ordering a test may include those considered but not selected.”
13. Comorbidities and MDM
Question: Do the comorbidities need to be noted in the MDM, or does mention of them in the HPI or PMH count?
Answer: Simply listing comorbidities is insufficient. Documentation must show how comorbidities impacted MDM for the ED encounter.
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.”
14. Pregnancy and MDM
Question: Should a coder or auditor consider a patient’s pregnancy as a factor in assigning the COPA and/or Risk level?
Answer: Yes. Pregnancy significantly impacts problem complexity and risk, even if the chief complaint is unrelated to pregnancy. Physiological and anatomical changes during pregnancy influence management and outcomes.
Pregnancy involves cardiovascular, hematologic, and musculoskeletal changes that complicate ED evaluation and treatment, including hypertension, pre-eclampsia, arrhythmias, and increased trauma susceptibility.
Pregnancy also affects diagnostic test interpretation. Hormonal changes alter lab values, requiring pregnancy-specific reference ranges. Uterine enlargement impacts accuracy of signs/symptoms and imaging for conditions like appendicitis or trauma.
Treatment risks in pregnancy are crucial. Medications safe for non-pregnant individuals may harm the fetus. Medication and intervention choices require careful consideration of maternal and fetal safety.
Any pregnant ED patient can reasonably be considered at least Moderate COPA. High COPA is appropriate if the illness/injury threatens mother or fetus.
Many ED diagnostic tests pose fetal distress or premature labor risk, especially in high-risk pregnancies. Imaging (non-extremity X-rays, CT, VQ scans) carries higher radiation risk, particularly in the first trimester.
Ordering or deferring these tests impacts “Amount and Complexity of Data.” Test performance risk is “high” in the Risk column.
Pregnancy Category C, D, or X medications are potentially harmful to the fetus, suggesting high-risk management decisions.
15. Differential Diagnosis and Data
Question: A documented differential diagnosis may help a coder or auditor understand the COPA for a patient presentation. When there is no clearly documented differential diagnosis, could a coder or auditor ascertain the potential diagnoses being considered based on the diagnostic tests that have been ordered and/or reviewed?
Answer: Yes. Differential diagnosis involves considering multiple potential causes for symptoms, based on history, exam, and diagnostic tests.
Even without explicit documentation, ordered tests imply the differential diagnosis. Reviewing the diagnostic workup reveals the potential diagnoses being investigated. Experienced coders/auditors should recognize this.
Test choices suggest specific conditions. Wrist x-ray for wrist pain suggests fracture/dislocation. Head CT after head trauma suggests intracranial injury concern. Chest pain with EKG and troponin suggests cardiac event investigation.
Without documented differential diagnosis, coders/auditors must understand diagnostic test significance and their implications for potential diagnoses.
16. Measuring Amount and/or Complexity of Data
Question: How is the Amount and/or Complexity of Data to be Reviewed and Analyzed measured?
Answer: Data complexity 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/QHP or appropriate source.
The MDM grid assigns value to components in these categories. Elements from each category are counted to determine if 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 |
17. “Scoring” Category 1 Data Elements
Question: How do I “score” the bulleted items in Category 1?
Answer: Each unique test, order, or document is counted individually. Different data elements can be combined (notes, tests, historian). Each item type or category doesn’t need representation. A unique test + note review + historian = three elements.
- Review of prior external note(s) from each unique source: External notes are records from outside the ED (inpatient charts, nursing home records, EMS reports, other ED charts). Unique source is a physician/QHP in a different group, specialty, or entity. Prior ED visits in the same ED group are not external records. Reviewing notes from each unique source counts as one element (e.g., discharge summary + nursing home records = 2 points).
- Review of the result(s) of each unique test: Tests are imaging, lab, psychometric, or physiologic data. CPT defines “unique test.” Clinical lab panels (BMP) are a single test. Repeating the same test (serial glucose, repeat EKG) during the ED visit is still one unique test. Pulse oximetry is now a vital sign, not a test for data complexity.
- Ordering of each unique test: Ordering a test includes reviewing results. One unique test ordered or reviewed is one data point. Ordering and reviewing the same test is not two points. Physician/QHP review of ordered tests is assumed. Reviewing tests ordered by another physician counts as test review (e.g., outside clinic, urgent care, nursing home tests reviewed in ED).
- Combination of Category 1 elements: Elements are summed. Lab test ordered + external note reviewed + independent historian = three points for Moderate/Extensive data. All Category 1 value can come from a single bulleted element. Ordering EKG, CBC, and CMP = three points from “Ordering of each unique test,” even though all are from the same bullet point. Ordering CBC, CMP, and cardiac troponin = three points, even though all are lab tests, as each has a unique CPT code.
18. Documentation for “Review of Prior External Note”
Question: What documentation is required to count “review of prior external note” in Category 1?
Answer: Primary documentation concern is accurate representation of the patient’s clinical condition and ED treatment. Document clinically relevant information for evaluation and management.
CMS 1995 E/M guidelines (“Relevant findings from review of old records should be documented”) and Marshfield Clinic E/M scoring (“Review and summarization of old records”) based policies are retired as of Jan 1, 2023.
Neither CPT nor CMS specify documentation standards for Category 1 data elements. CPT preamble: “These guidelines do not establish documentation requirements.”
CPT Assistant (Dec 2022) clarifies that “outside records reviewed” notation, without analysis or summary, counts as Category 1 data if the review is used in MDM for the current service.
19. PDMP Consultation as External Record
Question: Does consulting the prescription drug monitoring program (PDMP) electronic database count as a review of an external record?
Answer: Yes. PDMP consultation contributes to MDM by providing patient prescribing history to inform prescribing decisions. It qualifies as review of an external record.
20. Independent Historian Category
Question: Is “Assessment requiring an independent historian” Category 1 or Category 2?
Answer: It depends on the Data level. For Limited data, it’s Category 2. For Moderate and Extensive, it’s included in Category 1.
21. Definition of Independent Historian
Question: What is an independent historian?
Answer: An independent historian is:
- Any individual (EMS, parent, caregiver, guardian, spouse, witness) providing history in addition to the patient’s history.
- They should provide additional information, not just restate patient information (unless confirmation is needed).
- Physician/QHP may use historian when patient can’t provide complete/reliable history (developmental stage, mental status, urgency) or when confirmatory history is needed.
- Historian can provide all history if patient provides none (e.g., developmental age).
- History doesn’t need to be in person, but must be directly from the historian.
- Translation services are not independent historians.
22. Documentation for Independent Historian
Question: What documentation is required to count “Assessment requiring an independent historian” as part of the MDM?
Answer: CMS 1995 E/M guidelines-based policy requiring documentation of “patient’s condition or other circumstance which precludes obtaining a history” is not applicable after Jan 1, 2023.
CPT 2023 indicates historian use is appropriate when reliable history from the patient is unavailable or confirmation is needed. Physician/QHP uses a historian when clinically appropriate. CPT doesn’t require documenting why a historian was used or which history elements came from the historian.
CPT Assistant (Nov 2020) indicates historian can provide all history if the patient cannot. At minimum, document the source of history from anyone other than the patient (e.g., “history per mother,” “additional history from spouse”). Documentation style is at physician/QHP discretion or hospital/group policy.
23. EMS Discussion as Independent Historian or Category 3
Question: In the data column of the MDM grid, when the ED physician has documented a discussion with EMS, should that be counted in Category 1 as “Assessment requiring an independent historian,” or could EMS be considered and other appropriate source in Category 3 under “Discussion of management or test interpretation with external physician/other appropriate source”?
Answer: In most cases, EMS is an independent historian (Category 1). EMS discussions primarily focus on obtaining a comprehensive patient history: presenting complaint, medical history, accident details, etc. These are considered additional history from an independent source.
24. Independent Interpretation of Test (Category 2)
Question: What qualifies as an independent interpretation of a test for Category 2?
Answer:
- Any test interpretation with a CPT code and where interpretation/report is customary.
- ED examples: X-ray, EKG, ultrasound, CT scan, rhythm strip interpretations.
- Interpretation form should be documented (not needing a full report).
- If the CPT code for independent interpretation is separately reported, it cannot also be counted in Category 2.
25. Category 2 and EKG Interpretation (93010)
Question: Can I count Category 2 for independent interpretation of an EKG when I report 93010?
Answer: No. CPT states: “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.”
26. Category 2 and Non-Billed EKG Interpretations
Question: We do not bill for EKG interpretations (93010) in our practice. Can I count data points for the order of an EKG and the independent interpretation of the EKG?
Answer: Yes. Test orders not separately reported can be counted in Category 1. If documented, independent interpretation of the same test can also be counted in Category 2.
27. Category 2 for CBC/BMP Interpretation?
Question: 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”?
Answer: No. Category 2 is only for tests where interpretation/report is customary (EKG, X-ray, ultrasound, rhythm strip). Lab tests don’t have separate interpretation components.
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.”
28. Considered But Not Ordered Tests
Question: The physician/QHP considered the risks and benefits of a diagnostic test (e.g., x-ray or CT) and documented the rationale for not ordering the test. Would this still factor into the MDM in the data column?
Answer: Yes. E/M guidelines state test ordering “may include those considered but not selected.” CPT requires “considerations must be documented.” Physician/QHP documentation should explain why the test was not ordered.
29. Comparing Current and Prior X-rays as Interpretation
Question: 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?
Answer: Yes. Comparing recent x-ray findings to a previous x-ray is considered an independent interpretation.
30. “Discussion” for Category 3
Question: What qualifies as “discussion” for Category 3 – Discussion of management or test interpretation with external physician/other appropriate source.
Answer:
- Discussion requires interactive exchange.
- Exchange must be direct, not through nonclinical intermediaries.
- Sending chart notes or written progress note exchanges are not interactive.
- Can be asynchronous (not needing to be in person).
31. External Physician or Appropriate Source (Category 3)
Question: What is an external physician or another appropriate source for Category 3?
Answer:
- External physician/QHP: Not in the same group practice, or different specialty/subspecialty within the same group.
- Facility/organizational provider staff: Hospital, nursing facility, home health agency staff.
- Appropriate source: Non-healthcare professionals involved in patient management (lawyer, parole officer, case manager, teacher).
- Family or informal caregivers are not appropriate sources.
32. Documentation for Category 3 Discussions
Question: What documentation is required to give MDM credit for Category 3 – Discussion of management or test interpretation with an external physician/other appropriate source?
Answer: Chart should show ED physician/QHP had interactive exchange (in-person, phone, text, secure messaging) with an external physician/QHP or other professional involved in management. Category 3 discussions can be asynchronous, but timely (within a day or two) and contribute to current E/M service MDM.
Documentation style is at physician/QHP discretion (e.g., “discussed with cardiology” vs. “discussed with Dr. Smith“) and discussion details (e.g., “recommended repeat troponin/EKG in 2 hours” or “will accept admission“). Documentation content is hospital/group decision.
Marshfield Clinic E/M scoring based policies (“Review and summarization of discussion of case with another health care provider”) are retired after Jan 1, 2023.
33. Nursing Facility Discussion as Category 3
Question: Does the physician/QHP documentation of “Spoke with the nursing facility, they accept the patient for re-admission” qualify as MDM under Category 3?
Answer: Yes. DGs state external discussions can be with “facility or organizational provider such as from a hospital, nursing facility, or home health care agency.” Discussions about consultations, transfers, admit orders, post-ED management are clinically relevant, contribute to MDM, and count as Category 3.
34. Ordering and Discussing Tests (Category 1 & 3)
Question: Can I count Category 1 for the order of an X-ray or CT and also count Category 3 when the test is discussed with the radiologist?
Answer: Yes. Test ordering (Category 1) is separate from discussing films/images with the radiologist (Category 3). These are distinct elements.
35. Measuring Risk of Complications and/or Morbidity or Mortality
Question: How are the Risk of Complications and/or Morbidity or Mortality measured?
Answer:
- Risk assessment considers the nature of the event. Low death probability might be high risk, while high chance of minor treatment side effect may be low risk.
- Risk definitions are based on “usual behavior and thought processes” of specialists.
- Clinicians use common language for risk levels (high, medium, low, minimal), not necessarily quantification.
- MDM risk level is based on consequences of problems addressed when appropriately treated.
- Risk applies to patient management decisions made by the reporting physician/QHP.
- Risk includes MDM related to initiating or foregoing testing, treatment, and/or hospitalization.
MDM grid assigns risk levels (Minimal, Low, Moderate, High). Patient management decisions are assessed against these levels.
| 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 |
36. Additional Risk Examples for Emergency Medicine
Question: Are there additional examples of risk that would be applicable to emergency medicine, or can we establish additional risk elements within our practice?
Answer: AMA/CPT indicated listing all possible patient management decisions is impossible. Risk examples are not exhaustive.
2023 E/M Guidelines state physicians/QHPs have a common understanding of risk categorization (high, medium, low, minimal). Quantification isn’t required, but risk assignment should be based on usual specialist behavior/thought process.
37. No Minimal or Low Risk Examples
Question: Why are there no examples listed for Minimal or Low risk?
Answer: No published examples of minimal or low risk diagnostic testing or treatment exist.
38. Using 1995 DG Risk Table Examples
Question: Since there aren’t published examples of Minimal and Low risk, can the items from the CMS 1995 DG table of risk (e.g., rest, gargles, elastic bandages) be used to establish risk for a current E/M service?
Answer: AMA/CPT clarified (CPT Assistant, Nov 2020) that MDM focuses on physician/QHP work and decisions during the encounter. Prior MDM scoring may not accurately represent risk with the new process.
While the 2023 Risk Column is a reference, AMA/CPT indicates risk items are just examples.
Risk level for any procedure/treatment varies based on patient history, health status, and management decision during the encounter. Minor surgery or OTC meds can be low risk in some patients, but higher risk in others (e.g., diabetes, anticoagulation increasing infection/complication risk).
39. Throat/Nasal Swab as Risk Element
Question: When a throat or nasal swab is necessary for a diagnostic test, would it be appropriate to consider the performance of a throat/nasal swab as a risk element?
Answer: Yes, the decision for the diagnostic test is data complexity. The risk of the test performance is considered in the Risk Column.
Throat/nasal swabs for respiratory infections (strep, flu, COVID-19) are routine. Risks are low: patient discomfort, gagging, irritation, usually short-lived. Rare: minor bleeding or infection. Very rare: significant trauma. Generally Low Risk.
40. Venipuncture/IV Insertion as Risk Element
Question: When performing a venipuncture to draw blood for a diagnostic test or insert an IV, would it be appropriate to consider the performance of a venipuncture as a risk element?
Answer: Yes. Test order is data complexity. Blood draw risk is in the Risk Column.
Venipuncture/IV insertion is common in ED. Risks are generally low with proper protocols, but depend on patient factors.
Primary risk: infection. Hematoma/superficial thrombophlebitis is another risk. Nerve injury is rare.
Venipuncture/IV insertion risks are generally Low Risk.
41. Suture/Packing Removal as Risk
Question: Where would an ED visit for suture or packing removal fall in the Risk column in the MDM grid?
Answer: Risks of suture/packing removal from healed wounds are usually minimal and complications rare.
Primary risk: infection (minimal with aseptic technique). Rare: minor bleeding/discomfort, easily managed. Nasal packing removal is also minimal risk, with main concern being bleeding or tissue injury.
While usually minimal risk, risk varies by wound type/severity, patient health, underlying conditions/medications. Increased infection/complication risks (requiring repacking or antibiotics) elevate patient management beyond minimal risk. Minimal Risk is generally appropriate for uncomplicated suture/packing removal.
42. Work Release Evaluation as MDM
Question: How should the evaluation of a patient who presents to the ED for a work release score on the MDM grid?
Answer: Service level varies based on patient history, condition acuity, and work requirements.
Asymptomatic patient seeking work release for “doctor’s note” after brief history/exam is typically Minimal COPA and Minimal Risk.
If patient has symptoms needing evaluation/treatment, or if physician assesses re-injury risk and implements work restrictions, complexity/risk will be higher, likely exceeding Minimal.
43. Prescription Drug Management (Moderate Risk)
Question: What qualifies as prescription drug management in moderate risk?
Answer: Prescription drug management is documented provider administration, prescription, or evaluation of current medications during the ED visit. This includes ED administration of prescription meds (oral, IM, IV), prescriptions to be filled, medication discontinuation/modification, or maintaining current regimen after consideration.
44. OTC Prescription Dosage as Prescription Drug Management
Question: Can prescribing a prescription dosage of an over-the-counter medication qualify as prescription drug management?
Answer: Yes. Medication risk level depends on medication, dosage, and patient risk factors.
AMA/CPT: No blanket medication risk categories. Medication risk is low, moderate, or high based on patient factors. AMA/CPT webinar: “OTC NSAID in a person with kidney disease or on anticoagulants is of greater concern than most prescription drugs.”
Prescription dosage varies by age, weight, condition. Uncomplicated illness may need OTC dose (400mg ibuprofen). Higher risk patient with complex problem may need prescription ibuprofen (>400mg).
Pediatric OTC medications often need clinician direction due to age/weight/comorbidities (package inserts recommend physician consult). Pediatric OTC medication decisions can be Moderate Risk (acetaminophen <24 months, ibuprofen <6 months, diphenhydramine <6 years).
45. Tetanus Shot as Prescription Drug Management
Question: Would the administration of a tetanus shot be considered prescription drug management and support moderate Risk?
Answer: Yes. Tetanus shot adverse reactions are rare, but possible (mild: redness, swelling, aches; severe: fever, rash, allergic reaction).
Physician screens for prior tetanus shot complications (allergies, pain, seizures). Chronic/nervous system conditions may increase side effect risk.
Tetanus shots require a doctor’s order/prescription and FDA approval. It is a parenteral medication (injection). These factors suggest it exceeds Low Risk treatment.
Tetanus vaccination decision is consistent with Moderate Risk treatment.
46. Lidocaine Injection as Prescription Drug Management
Question: Would an injection of lidocaine, such as for a laceration repair or other procedure, count as prescription drug management?
Answer: Yes. Injectable lidocaine is prescription-only, supporting prescription drug management and Moderate Risk. OTC lidocaine patches/creams are low-strength and don’t require prescriptions. Injectable lidocaine has risks: anatomic structure damage, intravascular injection, seizures, arrhythmia.
47. Major vs. Minor Surgery
Question: What is the difference between Major and Minor surgery in the risk column?
Answer: Surgery classification (minor/major) is based on common clinical meaning, not surgical package classification.
48. Minor Surgery with Risk Factors (Moderate Risk)
Question: Are there examples of minor surgery with patient or procedure risk factors performed in the emergency department that could be considered at least moderate risk?
Answer: Procedure risk classification (minor/major, risk factors) is at physician/QHP discretion. Risk depends on patient-specific factors. Procedure deemed high risk for one patient may be moderate/low risk for another. Low-risk procedures may become Moderate Risk with local anesthesia (lidocaine – see Q46).
Patient risk factors for Moderate Risk: chronic condition (diabetes), medications (anticoagulants) increasing procedure risk or affecting recovery.
Procedure risk factors for Moderate Risk: emergent/urgent procedures for complex integumentary disruption (deep/contaminated laceration repair, complicated abscess treatment) or rigid musculoskeletal injury immobilization.
49. Elective vs. Emergency Surgery
Question: What is the difference between elective and emergency surgery in the risk column?
Answer: Elective procedures are planned in advance. Emergent procedures are immediate or with minimal delay. Both can be minor or major.
50. Risk Factors for Surgery
Question: What qualifies as a risk factor for surgery in the risk column?
Answer: Risk factors can be procedure-specific or patient-specific. Low-risk procedure in a patient with underlying condition increasing poor outcome risk can be Moderate or High Risk. Physician/QHP may use risk calculators (not required).
51. Social Determinants of Health (SDOH) (Moderate Risk)
Question: What are social determinants of health (SDOH) that may indicate moderate risk?
Answer: Economic/social conditions significantly limiting diagnosis/treatment (inability to afford meds, healthcare inaccessibility). Common ED SDOH: homelessness, unemployment, uninsured, substance abuse.
52. SDOH Documentation and Coding
Question: 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?
Answer: Medical record should reflect when diagnosis/treatment is significantly limited by SDOH. SDOH not required as final diagnosis. ICD-10 code for SDOH not required on claim.
ED-relevant SDOH ICD-10 examples:
- Z55.0 – Illiteracy
- Z56.0 – Unemployment
- Z57.6 – Occupational temperature exposure
- Z59.0 – Homelessness
- Z59.6 – Low income
- Z60.2 – Living alone
- Z62.0 – Inadequate parental supervision
- Z63.0 – Relationship problems
53. Language Barrier as SDOH
Question: Can treating non-English speaking patients and/or using a translator be considered a social determinant of health (SDOH)?
Answer: No. Language barrier is not on CDC, CMS, or ICD-10 SDOH lists.
Federally funded healthcare providers (Medicare/Medicaid) must provide language assistance services (translators). Title VI Civil Rights Act, Rehabilitation Act, ADA, ACA Section 1557 mandate effective communication with LEP patients.
Translator discussions cannot be independent historian or Category 3 discussion.
54. Patient-Reported SDOH and Documentation
Question: 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?
Answer: SDOH presence alone is insufficient. Risk table states “Diagnosis or treatment significantly limited by social determinants of health.” Documentation must show how SDOH was relevant to diagnosis/treatment.
55. CT Scan Order and Performance Risk
Question: Would it be appropriate to count the order for a CT scan in the data category and then consider the performance of a CT as a risk element?
Answer: Yes. CT scan decision (and interpretation) is data complexity. CT performance risk is in the Risk Column. Supported by CMS MAC references.
56. CT Scan Performance Risk Level
Question: Would the risk associated with the performance of a CT scan be consistent with at least Moderate risk in the Risk Column?
Answer: Yes. CT scans are common ED tools, but ionizing radiation poses cancer risk (higher in children, increased risk with scan number). Pediatric patients are more susceptible. ED physician must weigh risks/benefits, consider alternatives, and minimize radiation, especially in children.
Radiation exposure and other potential complications from CT scans are consistent with Moderate Risk when compared to Moderate Risk examples.
57. X-ray vs. CT Scan Radiation Risk
Question: How does the radiation exposure associated with non-extremity X-ray compare to that of a CT scan? Would the radiation exposure be consistent with moderate risk on the MDM grid?
Answer: Limiting radiation exposure is clinically important and a CMS Quality Program directive. Radiation measured in millisieverts (mSv). Typical background radiation: 2.4 mSv/year. Head CT: 1.6 mSv.
X-ray radiation varies greatly:
- Extremity x-ray: 0.001mSv (3 hours background)
- Chest x-ray: 0.1 mSv (2 weeks background)
- Lumbar Spine x-ray: 1.4mSv (6 months background)
Extremity x-ray risk is mild. Chest/lumbar spine x-rays have 100x more radiation than extremity x-rays, equating to months of background radiation, similar to head CT. Centralized x-rays (lumbar spine, chest) have more relative radiation and are Moderate Risk, compared to extremity x-rays (ankle, wrist, forearm) being lower risk.
58. IV Fluid Administration Risk
Question: Would it be appropriate to consider administering IV fluids in the emergency department at least a moderate risk management decision?
Answer: Yes. IV fluids are common and necessary, but have risks: infection, fluid overload, allergic reaction. Incorrect fluid/rate can cause life-threatening electrolyte/acid-base imbalances.
IV fluid administration risks, requiring physician/QHP order, are consistent with Moderate Risk examples like prescription drug management.
59. Rigid Musculoskeletal Immobilization Risk
Question: Would it be appropriate to equate rigid musculoskeletal immobilization in the emergency department with at least a moderate risk management decision?
Answer: Yes. Splinting/casting for fractures/dislocations is essential but has complications: compartment syndrome, pressure ulcers, joint stiffness, DVT, thermal injury.
Rigid immobilization risks in ED are consistent with at least Moderate Risk for MDM element “Risk of Complications and/or Morbidity or Mortality of Patient Management.”
60. “Drug Therapy Requiring Intensive Monitoring for Toxicity”
Question: What is needed to satisfy “Drug therapy requiring intensive monitoring for toxicity”? Has CPT or CMS published examples of qualifying medications?
Answer: Medications with potential for serious morbidity/death requiring monitoring for adverse effects. Monitoring is generally accepted practice and may involve lab tests, physiologic tests, or imaging (not history/exam alone).
CPT hasn’t published a “high-risk” medication list. AMA: clinicians understand patient/drug factors and when medication is high risk. Physician/QHP clinical judgment is key.
CMS MAC (Palmetto) published examples (many not ED-relevant).
ED-relevant examples (not all-inclusive):
| Adenosine | Isoproterenol |
|---|---|
| Amiodarone IV | IV contrast |
| Amrinone | Ketamine |
| Atropine | Labetalol IV |
| Bicarbonate IV | Lidocaine IV |
| Blood Products | Lithium |
| CA Gluconate | Magnesium IV |
| Caffeine IV | Metaraminol |
| Calcium Chloride | Metoprolol IV |
| Clevidipine | Methotrexate |
| Coumadin | Milrinone |
| Cyclosporine | Nicardipine IV |
| D50/Glucagon | Nitroglycerin IV |
| Dexmedetomidine | Nitroprusside |
| Digoxin IV | Nitrous oxide |
| Dilantin (phenytoin) IV | Norepinephrine |
| Diltiazem IV | Phenylephrine |
| Dobutamine | Potassium IV |
| Dopamine | Pregnancy Class D |
| Droperidol | Procainamide |
| Enalapril IV | Propofol |
| Ephedrine | Rocuronium |
| Epinephrine IV, IM, SQ | Sodium Chloride 3% IV |
| Esmolol | Sodium Nitroprusside |
| Etomidate | Succinylcholine |
| Gentamycin IV | Theophylline IV |
| Haldol IV | Thrombolytics |
| Heparin | Vancomycin IV |
| Hydralazine IV | Vasopressin |
| Insulin IV drip | Verapamil IV |
| Intravenous Vaso Active Medicines | Versed |
61. High-Risk Medications in Pregnancy
Question: Are there medications that should be considered high-risk patient management decisions when administered to a pregnant patient?
Answer: Yes. Pregnancy medication use requires caution due to fetal risks. FDA pregnancy categories (A-X, A safest, X highest risk).
- Category C: Limited human studies, fetal risks cannot be ruled out (potential fetal harm).
- Category D: Potential fetal risks. Use only if maternal benefit outweighs fetal risk. Risk classification doesn’t guarantee harm to every fetus.
- Category X: Contraindicated in pregnancy. Cause birth defects, developmental delays, miscarriage, fetal death.
High-risk pregnancy medication examples:
- NSAIDs: (ibuprofen, naproxen) – sparingly in pregnancy, especially 3rd trimester (Category B 1st/2nd trimester, D 3rd).
- Anticoagulants: (warfarin) – fetal risk, switch to safer alternatives (heparin, low molecular weight heparin – Category C).
- ACE inhibitors/ARBs: fetal harm (kidney damage, growth restriction – Category C 1st trimester, D 2nd/3rd).
- Antidepressants: (SSRIs) – Category D, potential birth defect/withdrawal risks. Benefit may outweigh risk for severe maternal depression.
- Anticonvulsants: (valproate) – Category D, birth defects/developmental delays. Seizure control benefit may outweigh medication risk.
- Methotrexate: Category X, contraindicated in pregnancy. Fetal malformations, growth restriction, fetal death.
This is not exhaustive. Many other medications are high-risk in pregnancy.
62. Emergency Major Surgery/High-Risk Procedures
Question: Are there examples of emergency major surgery or high-risk procedures performed in the emergency department that qualify as high in the risk column?
Answer: Emergent procedures are “immediately or with minimal delay for stabilization.” ED procedures considered major surgery/high risk:
- Displaced fracture care
- Intermediate joint dislocation reduction (TMJ, AC, wrist, elbow, ankle)
- Major joint dislocation reduction (shoulder, hip, knee)
- Chest tube
- Cardioversion
- Endotracheal tube
- Lumbar Puncture
- Thoracentesis
- Paracentesis
- Intraosseous Catheterization
- Central Venous Catheterization
- Arterial Catheterization
- Cardiopulmonary Resuscitation (CPR)
63. “Decision Regarding Emergency Major Surgery” Scope
Question: For the high-risk example “Decision regarding emergency major surgery,” does the ED physician/QHP have to perform the procedure, or does it include the ED physician/QHP referring the patient to the surgeon or admitting the patient for surgery?
Answer: Includes both. Risk determined by the decision surgery is needed, regardless of who performs it (ED physician, surgeon referral, admission for surgery). Supported by CMS MAC references.
64. “Decision Regarding Hospitalization” Scope
Question: Does “Decision regarding hospitalization” only apply when the patient is admitted to the hospital or observation?
Answer: No. “Decision regarding hospitalization” includes escalation beyond ED (Observation/Inpatient). Also includes decisions to forego further testing, treatment, or hospitalization. Hospitalization decision includes considering alternative care levels (psychiatric patient with outpatient support, palliative care for advanced dementia patient).
65. DNR/De-escalation of Care Decisions
Question: The physician/QHP discussed possible management options with the patient and/or family, including (but not limited to) end-of-life options, e.g., DNR status or de-escalation of care. The patient/family has opted for a “full code” status. Would this still qualify as a high-risk management option under the “Decision not to resuscitate or to deescalate care” bullet in the Risk column?
Answer: Yes. Risk element includes explaining risks/benefits of management options (selected and not selected) after shared decision-making with patient/family, even if “full code” is chosen.
66. Parenteral Controlled Substances (High Risk)
Question: Which medications qualify as parenteral controlled substances in the high section of the risk column?
Answer: It’s not just the medication, but the route of administration plus the medication (parenteral + controlled substance – Schedule I-V).
ED-relevant examples (not all-inclusive):
| Buprenorphine (Suboxone) | Morphine |
|---|---|
| Diazepam (Valium) | Nubain (nalbuphine) |
| Fentanyl (Sublimaze, Duragesic) | Pentobarbital |
| Hydromorphone (Dilaudid) | Phenobarbital |
| Ketamine | Stadol (butorphanol) |
| Lorazepam (Ativan) | Sufentanil |
| Meperidine (Demerol) | Talwin (pentazocine) |
| Methadone (Dolophine) | Thiopental |
| Methohexital | Versed (midazolam) |
| Midazolam (Versed) |
67. Considered But Not Ordered Options (MDM Complexity)
Question: 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?
Answer: Yes. Need to initiate or forego testing/treatment/hospitalization is an MDM complexity factor. Examples: risk/benefit analysis, risk calculators, shared decision-making leading to not ordering a test or choosing a different management path.
68. IV Contrast for CT Scan Risk
Question: Could the risk associated with using IV contrast for a CT scan be considered high risk in the Risk Column?
Answer: Yes. IV contrast for CT is valuable but carries risks: allergic reaction (anaphylaxis), kidney damage (contrast-induced nephropathy, especially in pre-existing kidney issues).
ACR requires physician/PA/NP trained in anaphylaxis management to directly supervise IV contrast administration. Supervision provider must be immediately available.
CT with contrast risk is appropriately considered High Risk management decision.
69. Moderate Sedation Risk
Question: Could the risk associated with moderate sedation be considered high in the Risk Column?
Answer: Yes. Moderate sedation manages pain/anxiety but has risks: respiratory depression, cardiovascular complications (hypotension, bradycardia, tachycardia), allergic reactions (mild to severe).
These potentially life-threatening complications make moderate sedation a High Risk management decision.
70. Sedating Agent Use Risk
Question: Would it be appropriate to consider the use of sedating agents in the emergency department as a high-risk patient management decision?
Answer: Yes. Sedatives (benzodiazepines, propofol, ketamine, etomidate, dexmedetomidine) affect breathing, can cause blood pressure drops, anaphylaxis, paradoxical reactions, and other life-threatening complications, making their use a High Risk management decision.
71. Physical Restraints/Security Watch Risk
Question: Could the use of physical restraints or placing a patient under watch (e.g., Line of Sight Observation or equivalent) for patients with altered awareness, mental status changes, agitation or other behavioral issues be considered high risk in the MDM grid?
Answer: Yes. Physical restraints have risks: physical injury, psychological trauma, respiratory compromise, circulatory compromise. Use is limited to extraordinary situations, making it a High Risk management option.
Security watch can also cause behavioral decompensation and increased agitation, considered High Risk.
72. Anticoagulant Therapy Risk
Question: Could anticoagulant therapy initiated in the ED (e.g., warfarin, enoxaparin, heparin) or direct-acting oral anticoagulants (DOAC) qualify as a high-risk management decision on the MDM table?
Answer: Yes. Initiating anticoagulation (enoxaparin, heparin, DOACs) for DVT, AFib, PE, stroke, etc., is High Risk due to bleeding risks and drug-drug interactions. Especially high risk in patients with bleeding disorders or on other bleeding risk medications.
73. 99281 and Triage-Only Patients
Question: Since 99281 does not require the presence of the physician/QHP, can 99281 be reported when an ED patient is registered and triaged by the nursing staff but leaves before being evaluated by a physician/QHP?
Answer: No. 99281 requires an E/M service, not just triage. Triage alone is not an E/M service and cannot be reported with an E/M code.
74. 99281 and Services Beyond Triage
Question: As of 2023, E/M code 99281 does not require the presence of the Physician/QHP. Can 99281 be reported when an ED patient is registered, assessed by nursing staff, and then receives services beyond the initial triage, such as the removal of sutures, without the need for a physician/QHP to physically see the patient?
Answer: Yes, for 99281, face-to-face services can be by clinical support staff under physician/QHP direct supervision. 99281 RVUs reflect physician/QHP supervisory role.
MACs (NGS, FCSO) indicate 99281 is for straightforward ED care not needing physician/QHP active participation, but requiring direct supervision (physician immediately available, not needing personal bedside presence).
Examples: suture removal, simple dressing change, reviewing prior instructions.
99281 requires supervision and an E/M service documented by clinical team. Medicare requires documented date/signature from billing provider. Physician/QHP can review/verify notes instead of re-documenting.
75. 99281 and Resident/Student Evaluations
Question: With 99281 no longer requiring the presence of the ED physician, can 99281 be reported when a patient is evaluated/treated by a resident or student and then elopes or is discharged before being evaluated by the teaching physician?
Answer: No. CMS Teaching Physician policies unchanged. Teaching physician must be physically present during key/critical portions of resident services (same room). For student services, teaching physician must personally perform (or re-perform) physical exam and MDM.
76. 2023 Guidelines and PA/NP Shared Services
Question: How do the 2023 E/M guidelines affect documentation and coding when a PA/NP has provided a portion of the patient care, and the attending physician will report the visit as a shared service?
Answer: AMA revised “split/shared visits” definition for 2024, defining “substantive portion” as >half total time or substantive MDM part. Determines billing provider (physician or QHP).
Substantive MDM part means physician/QHP made/approved management plan and takes responsibility for it. This fulfills two of three MDM code level elements.
CMS adopted CPT definition of substantive portion for 2024.
77. Attending Physician Documentation for Shared Services
Question: Does the attending physician have to document their medical decision making for PA/NP shared E/M services, or must their attestation indicate what elements of the E/M service they provided to support reporting a shared service?
Answer: ED physician can review/approve PA/NP documentation and attest to substantive MDM portion (e.g., “I personally made/approved management plan and take responsibility“).
If code relies on Data Category 2/3 (interpretation/discussion), physician documentation should include interpretation/discussion reference. Attestation can include interpretation/discussion.
If ED physician documents MDM elements performed (plan, interpretations, meds, discharge instructions), attestation is not required. Attestation example is alternative to re-documenting PA/NP’s plan/MDM.
78. Observation E/M Code Application
Question: Do these guidelines apply to the observation E/M codes also?
Answer: Yes. Observation services use MDM guidelines or time-based coding.
Initial Observation Care (99218-99220), Subsequent Observation Care (99224-99226), and Observation Discharge (99217) codes were deleted for 2023.
Inpatient E&M codes (99221-99223, 99231-99239) revised to Hospital Inpatient and Observation Care Services.
79. Urgent Care E/M Codes
Question: 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?
Answer: Yes. Office/Outpatient E/M codes (99202-99215) have used revised guidelines since Jan 2021. Based on MDM or Time, using the same MDM grid. Code descriptors indicate time for each service level.
80. Guideline Source
Question: Where can I find the complete set of guidelines?
Answer: Evaluation and Management (E/M) Services Guidelines section of the 2023 CPT Manual. Downloadable link provided.
81. 2023 MDM Grid Source
Question: Where can I download a copy of the 2023 MDM Grid?
Answer: Only official source is the 2023 CPT book.
This revised article provides a comprehensive guide to the 2023 Emergency Department E/M coding guidelines, focusing on Medical Decision Making and addressing common questions for coding professionals. Remember to always consult the official CPT manual for the most accurate and up-to-date information.
