Making Sense of the 2023 Documentation Updates: Part 2

The 2023 ED E/M documentation rules shifted billing away from checkbox history and exam requirements and onto medical decision making. In emergency medicine, chart level now lives in COPA, data reviewed, and management risk, with the final level based on the highest 2 of 3 categories.

2023 ED E/M Documentation Changes

• MDM now drives billing: HPI, ROS, and physical exam no longer have minimum element counts for ED billing; chart level is determined by medical decision making rather than Marshfield-style box checking.
• Pertinent history still matters: A brief HPI can support a high-level chart if the MDM justifies it, but the note still needs enough clinical detail for coders and colleagues to mentally picture the patient.
• Focused exam is acceptable: There is no billing requirement for a full physical exam, yet a targeted organ-system exam remains clinically important for communication, risk framing, and medicolegal protection.
• Combined history workflow: HPI and ROS can be merged for billing purposes, and separate past, family, and social history sections are not required if the relevant details are captured where they matter.
• Critical care separate lane: If you are billing critical care, you do not also bill an E/M code, which prevents wasted effort trying to optimize both frameworks at once. We get into the practical implication in the episode.

How to Score MDM Correctly

• Highest two categories rule: Final ED billing level is set by the highest 2 of 3 MDM domains: complexity of problems addressed, data reviewed, and risk of patient management.
• COPA favors clinical complexity: Complexity of Problems Addressed reflects the seriousness of the possibilities you are working through, not the eventual diagnosis; abdominal pain is a classic moderate-complexity presentation.
• Comorbidities belong in MDM: Document how chronic illness changes the current presentation in the MDM, because a chemotherapy patient with fever carries a very different risk signal than a healthy teenager.
• Either order or review: For a given test in the current encounter, you get credit for ordering it or reviewing/interpreting it, but not both; that either-or rule is one of the easiest places to overcount.
• Independent historian nuances: An independent historian must be someone other than the patient providing necessary history; interpreters do not count because they relay rather than originate information. We walk through the common edge cases in the chapter.
• Deferred test still counts: Documenting a considered but not ordered study can earn data credit when clinically justified, such as using PECARN to support not obtaining a pediatric head CT.

Risk Documentation and Billing Pearls

• Prescription management counts: Moderate risk includes prescription drug management, and that category is broader than many realize, extending to parenteral medications and procedures like lidocaine injection.
• Social risk belongs here: Social determinants such as homelessness or limited transportation can support the risk element when they materially affect evaluation, treatment, or safe follow-up planning.
• High-risk management examples: High risk includes decisions about hospitalization, drug therapy requiring toxicity monitoring, and de-escalation of care because prognosis limits aggressive treatment.
• Interpretation versus separate billing: If your own EKG interpretation is what pushes the chart to a higher MDM level, folding it into the note may be smarter than billing a separate interpretation code.
• Useful coding reference: ERnotes.net is a free emergency medicine billing resource that helps translate the 2023 grid into usable documentation habits without defaulting back to template inflation.

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