Making Sense of the 2023 Documentation Updates: Part 1

The 2023 ED E/M documentation update moved billing away from checkbox history and exam requirements and onto medical decision making. For emergency physicians, that means the note has to show problem complexity, data work, and management risk clearly enough for coding, handoffs, and medicolegal defense.

2023 ED E/M Documentation Changes

• MDM now drives billing: ED billing levels are now determined by medical decision making rather than counting HPI, ROS, or physical exam elements, a major shift from the old Marshfield-style checkbox approach.
• Lean history and exam: There is no billing requirement for a specific number of HPI, ROS, or exam elements, so the note can stay focused on clinically pertinent details that let others picture the patient.
• Combined note sections: HPI and ROS can effectively be merged for billing purposes, and past medical, social, and family history do not need separate sections if the relevant details are captured clearly.
• Two of three rule: The final E/M level comes from the highest 2 of 3 MDM categories: problem complexity, data reviewed, and management risk. We walk through how that changes charting priorities in the episode.
• Level mapping update: Straightforward through high MDM still map to ED visit levels, but 99281 has been removed from ER billing, narrowing the practical coding range to 99282 through 99285.

Documenting Stronger MDM in the ED

• COPA reflects concern: Complexity of Problems Addressed is driven by the seriousness of the differential and the patient's context, so abdominal pain or fever on chemotherapy can support higher complexity than the final diagnosis suggests.
• Comorbidities belong in MDM: Document comorbidities and risk factors in the MDM, not just the HPI, so coders can see why those details matter to the current presentation and management choices.
• Either order or review: For a test from the current encounter, you get credit for ordering it or independently interpreting it, but not both; that either-or rule is one of the easiest places to lose points.
• Independent historian nuance: An independent historian must be someone other than the patient providing needed history for a justified reason; interpreters do not count because they relay rather than originate information.
• Considered but deferred tests: Documenting that you considered a test and appropriately did not order it, such as applying PECARN to defer pediatric head CT, can still count in the data section. That bedside wording is worth hearing in the chapter.
• Risk category anchors: Moderate risk includes prescription drug management and social determinants of health, while high risk includes decisions about hospitalization, toxic therapies, or major escalation and de-escalation choices.

References:

1. 2023 Emergency Department Evaluation and Management Guidelines.  American College of Emergency Physicians. Published November,  2023.  Accessed May 15, 2023. https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs#:~:text=How%20do%20the%202023%20E,Decision%20Making%20or%20Total%20Time
2. Documentation for ER Physicians.  ER Notes.  Published 2023.  Accessed May 15, 2023.  ERnotes.net