Here’s the new language clinicians need to learn with updated documentation guidelines
A Game-Changing Era Has Arrived:
Beginning in January, a paradigm shift of documentation requirements for reimbursement in Emergency Medicine will take effect. New AMA CPT guidelines will dictate what it takes to get paid optimally for the service we provide. The charting criteria we have relied on for over 25 years will change significantly — in certain areas dramatically. Take heart, Emergency Medicine physicians, these changes will not impact your day-to-day patient care. Moreover, with the key foundational insights that follow, you can learn the “new language” needed to succeed and obtain appropriate reimbursement.
In Some Ways Things Are Easier:
In regard to Emergency Department charting and AMA CPT Evaluation and Management (E/M) Services (CPT 99281 – 99285), Medical Decision Making will now take center stage. In 2022, recall all of the stringent criteria for meeting the requirements for your level 5 (CPT 99285) encounters? As a review, these are => 4 elements for History, 8 organ systems for Physical Exam, 10 Review of Systems, 2 areas of Past Medical / Family / Social History. Now for the good news — all of these go away as of January 2023.
Moving forward, the AMA 2023 Documentation Guidelines necessitate solely “a medically appropriate history and/or examination” for the majority of Emergency Department E/M encounters (CPT 99282 – 99285). Of note, CPT 99281 visits are defined for those encounters considered so basic that these “may not require the presence of a physician or other qualified health care professional”.
For all other E/M encounters (CPT 99282 – 99285), Medical Decision Making elements will determine the ultimate level of service. The following categories will be used: for CPT 99282 “straightforward,” CPT 99283 “low,” CPT 99284 “moderate,” and CPT 99285 “high” medical decision making, respectively.
These point of reference terms are vital to recognize in our new language of Emergency Medicine reimbursement. As such, best practice charting should target in on Medical Decision Making elements. Nonetheless, don’t dismiss the value of detailing a solid History and Physical in 2023. Your documentation of these will support the degree of complexity and risk that reside within a given patient encounter. Your vigilance here will certainly be important to both your coders and payers.
The Language We Must Speak:
In regard to the new 2023 AMA CPT Documentation Guideline framework, key terms to keep in mind are “acute complicated injury,” “acute illness with systemic symptoms” and “chronic illness with severe exacerbation.” This is some of the pivotal language you must learn to master. The goal is to properly convey the appropriate “Number and Complexity of Problems Addressed” to your medical coders. In your charting, be sure to highlight the applicable acuity, detail systemic symptoms and note the severity of illness. When applicable, descriptive words (such as “generalized weakness,” “fatigue,” “fever,” “chills,” and “rigors”) really do matter.
Also, consider including a Differential Diagnosis with your documentation. In many cases, this can alert your coders that you are managing an encounter with a potential “threat to life or bodily function” (high complexity) as a cause of the presenting problem. As a medical-legal aside, always include “other” in your differential diagnosis — both in your critical thinking and everyday charting.
When appropriate, here’s how your documentation could look:
1) “The patient a 36 y/o female with a chief complaint of acute abdominal pain. She reports her discomfort began earlier this morning. The patient reports having associated chills and generalized weakness.”
2) “The patient is a 74 y/o male with a chief complaint of elevated blood pressure. He has a history of hypertension. His blood pressure was reportedly 230/120 earlier today despite taking his medication. The patient states his readings are usually around 140s/80s.”
3) “Differential Diagnosis – GERD, Musculoskeletal, ACS, Pneumonia, Pneumothorax, PE, other”
Your Actions Add Up (Literally) – Here’s What Counts:
Similar to the past, the “Amount and/or Complexity of Data” that is ordered and/or reviewed will also factor into determining which E/M level (CPT 99282-99285) is assigned for each patient encounter. Credit will be marked for the various tests and actions you perform.
Be sure that your chart reflects when Labs are ordered and/or reviewed. If labs automatically populate in your note and are signed off by you, then you don’t need to double document (i.e. not necessary to chart “ordered”). However, if they don’t auto-populate, be sure to specify these in your note so that credit is given. Ordering and/or reviewing 3 unique tests (individual labs included) counts towards the Moderate and Extensive levels of Data reviewed.
Likewise, ensure that X-rays and other imaging are accounted for when they are ordered and/or reviewed. Additionally, document whenever you have Independently interpreted an image or tracing (i.e. X-ray or EKG). In these arenas, phrases such as “ordered / reviewed” and “as interpreted by me” can make your actions crystal clear to your coders.
Your documentation could look like this:
1) “3 Labs ordered / reviewed. Troponin is negative.”
2) “Chest X-ray no focal infiltrate, no pneumothorax as interpreted by me.”
Another area of Medical Decision Making value revolves around your discussions with others. Your conversations in Emergency Medicine matter – now more than ever. As such, be sure to document:
1) Use of an independent historian. Obtaining history from a spouse or caregiver with an incapacitated patient? Always reference this in your charting (with brief elaboration).
2) Discussions of results with the radiologist. Receiving a call from your radiologist regarding a patient’s CT code stroke results? Be sure to document this – it is important.
3) Discussions of management with other health care providers. Admitting a patient to the primary physician service? Consulting a specialist? Always detail these conversations in your charting. Also, be sure to document your discussions with social workers or skilled nursing facility staff who are involved in the management of the patient. You will get credit.
Your documentation could look like this:
1) “The patient’s wife was at bedside and she contributed to the patient’s history. The patient arrived with altered mental status and was unable to communicate. The wife indicated he was last seen awake and alert last evening.”
2) “I discussed CT head results with the radiologist – he reports no acute bleed.”
3) “The hospitalist was consulted by phone, management discussed, and she will admit the patient.”
Additionally in 2023, here’s some Medical Decision Making data points that are new:
1) “Review of prior external notes.” Reviewing medical provider notes, labs or tests from a source separate from your Emergency Medicine practice group? Be sure to include this in your documentation. This would include a consultant’s prior notes or testing (e.g. labs, ECHO, stress test) even if performed at the same hospital.
2) “Test considered but not ordered.” Considering a study for a diagnostic work-up though your decision making tool, clinical gestalt or patient factors dictate otherwise? Document that you “considered” the test — this action can make a difference in the E/M level (CPT 99282-99285) assigned.
Your documentation could look like this:
1) “I reviewed the cardiologist’s cath lab report and the patient had 2 coronary stents in December 2018.”
2) “I considered a CT Chest Angiogram in the work-up for this patient. However, the patient has no history of recent long car ride or plane trip and d-dimer is negative. Therefore, I did not order a CT scan.”
Risk & Complexity Still Matter (and New Twists):
The final section of Medical Decision Making aligns under “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This section is similar to the previous Table of Risk used by our coders nationwide for years. In 2023, these elements continue to factor into your level of E/M service for each patient encounter. Keep in mind, there are virtually no “trivial” interventions in Emergency Medicine. It takes only one element within a risk level for that level of risk (“minimal,” “low,” “moderate” or “high”) to be attributed to a particular encounter.
In this arena, the Moderate Risk Level includes such elements as: “Prescription drug management” and “Decision regarding minor surgery with identified patient or procedure risk factors.” Either of these will establish moderate risk. When charting your “decisions regarding surgeries”, be sure to link the underlying factors / co-morbidities to the specific increased risks involved. For example: “Suture repair of this patient’s forearm laceration involved consideration of the patient’s 18-hour delay in seeking care, his pre-existing diabetes, and the risk of infection with closure.”
Within the same section, the High-Risk Level includes such elements as “Drug therapy requiring intensive monitoring” (e.g., diltiazem drip), “Decision regarding emergency major surgery,” “Decision not to resuscitate or to de-escalate care because of poor prognosis” and “Parenteral controlled substances” (e.g., morphine IV). Any one of these will establish high risk.
Always keep in mind — your charting will help substantiate the E/M level of service you have provided.
Interestingly, AMA CPT Guidelines have been rather vague in regard to the classification of “minor” and “major” surgeries – stating these are “based on the common meaning of such terms when used by trained clinicians.”
Similarly obscure, “patient or procedure risk factors” impacting the decision regarding surgery – these are described as “those that are relevant to the patient and procedure.”
Fortunately, the description of an “Emergency” procedure is more precisely defined as “typically performed immediately or with minimal delay to allow for patient stabilization.”
In any event, here’s how your documentation could look:
1) “An emergent chest tube was indicated in the management of this patient as he presents with an acute large pneumothorax.”
2) “The patient was ordered IV diltiazem for her atrial fibrillation and thus required continuous cardiac monitoring.”
3) “I discussed DNR status in detail with this critically ill patient and he directed that he is DNR/DNI and no pressors.”
4) “The patient presented with severe back pain after a fall off ladder and thus required IV morphine.”
Moving forward, this is what’s new for 2023:
1) “Diagnosis and treatment significantly limited by social determinants of health.” This includes patient-centered issues such as homelessness, illiteracy, and financial insecurity. This element is now within the Moderate Risk level. If your choice of drug prescription, diagnostic test, or decision to admit a patient is influenced by that patient’s refusal due to their insurance (or lack thereof), be sure to detail this in your charting.
2) “Decisions regarding hospitalization or escalation of care.” This is important – it now factors in and is found within the High-Risk level. If a patient’s presentation warrants hospital admission, be sure to document a brief note in your medical decision making. This also applies to nursing home placement or even home health care arrangement.
Here’s how your documentation could look:
1) “The patient refused my prescription for metaxalone due to his lack of insurance coverage. As such, I prescribed cyclobenzaprine for this patient instead. We did discuss the risks of drowsiness while taking this medication.”
2) “My decision to admit – The patient is morbidly obese with uncontrolled diabetes and has multi-focal pneumonia. Therefore, I feel IV antibiotics and hospitalization are warranted for this patient’s care.”
Your Final Diagnosis – Important? … Maybe Not or Maybe So?
The 2023 AMA CPT Documentation Guidelines specifically support what ACEP, ACOEP, EDPMA and other groups have been advocating for years – that a clinician’s final diagnosis alone cannot be used to dismiss the level of complexity and risk within a case. The AMA language 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.”
This is good news for our patients to protect them against insurance denials. It essentially defends the prudent layperson against being penalized for ultimate diagnosis such as “bronchitis” or “GERD” despite the patient having serious concerns about their presenting illness.
On the flip side, the AMA CPT guidelines also acknowledge that “multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.” Thus, appropriately charting multiple diagnoses may provide your coders a more accurate picture of the risk and complexity within an encounter. Be sure to list the most serious diagnosis first.
In this arena, your documentation may look like this:
1. Closed head injury
2. Generalized weakness
1. Olecranon bursitis
2. Puncture wound
Finally, For Those Serious About Critical Care:
Critical Care Time CPT codes 99291 and 99292 will not be directly affected by the 2023 AMA CPT Documentation Guidelines. Accordingly, keep charting your Critical Care services as you always have => i.e.“I spent 30 minutes of Critical Care Time with this patient.
This does not include time spent on separately reported billable procedures.” AMA CPT Guidelines will continue to recognize billable Critical Care Time with pivotal marks at 30 minutes, 75 minutes, and every 30 minutes of Critical Care provided thereafter (105, 135, etc.)
However, in 2023, CMS (Centers for Medicare and Medicaid Services) will be instituting their own new standard of submittable Critical Care Time provided by individual clinicians. While CMS will still recognize Critical Care Time at the 30-minute mark, the 99292 threshold will not be considered complete until 104 minutes of Critical Care service has been provided.
Thus, under CMS, new pivotable marks will reside at 30 minutes, 104 minutes and every 30 minutes thereafter. Quite a set-back for physicians! This is sure to create a bit of chaos — some payers will adhere to AMA CPT Critical Care thresholds and others will follow CMS. Hold on to your seats Emergency Medicine.
Remember best practice is to document your Critical Care Time as accurately as you can. Rather than charting just a range of care (i.e. 75-104 minutes), strive to be precise. Here’s how your documentation should look:
“I spent 90 minutes of Critical Care Time with this patient. This does not include time spent on separately reported billable procedures.”
In Conclusion, Our Road Ahead / The Journey Continues:
That’s your roadmap for reimbursement success in 2023 and hopefully for many years beyond. As always, nuances to these guidelines will evolve over time. As such, continue to stay vigilant and ready to adapt. Remain attentive, and you can not just persevere, but also thrive in Emergency Medicine. Best wishes!
**Peer Reviewed by David Friedenson, MD FACEP. Reventics, an Omega Healthcare company: Chief Medical Officer / EDPMA: QCDC.**