Brace For Impact: Incoming Documentation Changes

ED documentation changed in 2023 by shifting chart leveling away from history and physical exam toward medical decision-making. The practical implication is less note bloat and more emphasis on documenting your differential, actions, discussions, and social determinants of health.

2023 ED Documentation Changes

• MDM becomes the center: History and exam still matter clinically, but they no longer drive ED chart leveling; the billable work is increasingly the medical decision-making you capture in the note.
• Four D charting frame: A durable bedside structure is Differential, Doing, Discuss, and social Determinants of health, which turns vague note-writing into defensible documentation. We walk through that frame in the episode.
• Targeted differential language: Avoid sprawling complaint-based dot phrases; a focused differential tied to the actual workup, with named rationale such as Wells or PERC, is both cleaner and more credible.
• Rationale for tests ordered: Modern E/M logic gives credit not just for tests and treatments you do, but also for studies you deliberately defer when the chart clearly states why.
• Recognizing chronic instability: Asymptomatic hypertension or hyperglycemia can still count as unstable chronic illness when not at goal, provided you recognize it and document a plan such as PCP follow-up.
• Social determinants as risk: Homelessness, injection drug use, and threat of job loss now belong in the MDM risk picture, reflecting a major shift from older coding priorities toward health equity.

References:

1. https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/em_changes_FAQ.html
2. https://www.cms.org/articles/2021-cpt-evaluation-and-management-e-m-coding-changes