On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service 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. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level. The critical care codes (99291 and 99292) were not impacted by the 2023 documentation guideline changes.

New Coding Rules: Medical decision making will determine your visit level and 85 percent of the typical group’s RVUs.

Medical decision making (MDM) in 2023 is too complicated to fully address here, but it will still be based on the modified historic three MDM components with the eventual level assigned scored using the highest two of three components:

1. Number and complexity of problems addressed—There is no longer a major distinction made for additional workup planned, and no longer points for a new problem to the examiner. The 2023 requirements will be less numeric and more qualitative, including terms such as acute uncomplicated injury, acute illness with systemic symptoms, and chronic illness with severe exacerbation.
2. 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. New changes include points awarded for review of prior external notes and use of an independent historian, in addition to points for testing you considered but did not order (such as a pediatric head CT for a minor blunt injury).
3. 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. At the moderate risk level, important changes for 2023 include diagnosis and treatment significantly limited by social determinants of health and prescription drug management considerations. At the high-risk level, credit is now given for decisions regarding hospitalization or escalation of care.

Beyond the new MDM table, other favorable 2023 language includes:

• “The final diagnosis for a condition does not in 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.” This helps reinforce the concept of the prudent layperson standard.
• “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
• “Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition. The discussion of the lack of benefit may be required. Alternatively, a test may be normally performed, but due to the risk for a specific patient, it is not ordered. These considerations must be documented.”

Centers for Medicare & Medicaid Services (CMS) is on record through the rule making process that it will adopt the MDM guidelines as revised by CPT, if not all the prefatory language and interpretive guidance framework issued by the AMA CPT, because it believes it would help reduce the burden.

Take a Deeper Dive

ACEP offered a special briefing web conference on the introduction of the 2023 Emergency Medicine E/M Documentation Guidelines 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. A recording of that conference is available on demand until Sept. 14, 2022, in ACEP’s Online Learning Center.

Dr. Granovsky is presenting “RVU Killers 2023 Brand New ED Documentation Guidelines: Avoid Mistakes and Maximize Opportunities” during the upcoming 2022 ACEP Scientific Assembly on Oct. 1, at 4:30 p.m. PT.  

Dr. Granovsky is the President of LogixHealth, a national ED coding and billing company processing over 13 million annual encounters and serves as the course director of the ACEP Reimbursement Conference. He can be reached at: mgranovsky@logixhealth.com

Mr. McKenzie is the ACEP Director of Reimbursement and staffs the ACEP CPT and RUC Teams. He can be reached at dmckenzie@acep.org