In medicine, the story we record is not an unfortunate consequence of our bedside care but a vital aspect of this compassionate work. Documentation is the clinical voice that communicates judgment, complexity, and intent long after the patient encounter has ended.
It shapes how care is understood, how decisions are defended, and how outcomes are measured. In an era of increasing scrutiny from regulators, payers, and peers, precise and thoughtful documentation is no longer optional; it is essential.
Our documentation serves multiple critical functions, beginning with patient care, where it communicates our clinical reasoning to the broader healthcare team and ensures continuity across consultants, inpatient providers, and outpatient clinicians. It also provides essential liability protection by clearly capturing the rationale behind our decisions.
What we record represents the primary evidence of the excellent care we have provided in the event of a medicolegal review. Finally, documentation directly supports billing and reimbursement, as it establishes the level of complexity for an encounter, which ultimately determines the appropriate compensation for the services rendered.
It is this final function that may be the least intuitive for an emergency medicine clinician and requires the greatest level of education to reasonably grasp. Current coding guidelines are the result of an extensive effort to attribute distinct value to our clinical work. I like to think that a simple system of coding would be an insult to the awesome complexity of the care we provide.
As such, let us dive into the broad strokes of emergency medicine documentation as it relates to our coding and professional fee billing. This story starts with the assignment of CPT codes based on the clinical activities documented, it moves through the final diagnoses attributed with ICD-10 codes, and it ends with relative value units that are converted to dollars. I will explore each in turn.
In 2023, a seismic change occurred in how our documentation would be coded and subsequently reimbursed for our professional component. The change was meant to reduce burden and focus on the mental work undertaken by clinicians. This was a very good thing. Overnight, billing complexity moved further away from the quantity of words documented, and toward the clinical thought process needed to provide exceptional care for the patient.
An appropriate history can now be determined by the clinician, eliminating the requirement for an arbitrary number of elements. Eight organ systems only need to be examined if they clinically need to be examined, what a novel idea. Maddening statements like “A complete review of systems was reviewed and negative” could finally be thrown into the waste bin of documentation history.
The new guidelines also defined that the emphasis on final diagnoses, which was always discouraged, is outright inappropriate. The work involved in evaluating an entire patient, determining what was and was not needed through considerations and shared decision making, ruling out emergent conditions in complex clinical situations, as well as determining the risks of treatment have taken primacy in establishing the level of encounter complexity.
Naturally, 2023 didn’t change everything. Our charts had previously been assigned the long-standing emergency CPT codes created by the American Medical Association, including 99281 though 99285, which were converted to bills and reimbursement.
These codes continue to be assigned with the same purpose, but changes in 2023 reshaped the criteria of CPT assignment to focus on a more accurate clinical complexity.
99281 was converted to a code for emergency medicine evaluation that may not require the presence of a physician or other qualified health care professional. As a testament to our craft, this code would have little if any actual use.
- 99282 straightforward complexity
- 99283 low complexity
- 99284 moderate complexity
- 99285 high complexity
Critical Care, with CPT code 99291, continues to represent our highest level of care involving critical interventions for those patients suffering critical illness or injury.
Keep in mind that documentation does not create this complexity, but it must accurately capture the complexity that exists in your clinical decision making. These codes and their associated increasing level of complexity correspond to the level of medical decision making with resultant increasing reimbursement through Relative Value Units (RVUs).
What is an RVU, and who is assigning them?
Each CPT code is assigned a number of Relative Value Units (RVUs) by the Centers for Medicare and Medicaid Services (CMS).
The total RVU includes three components:
- Work RVU
- Practice expense RVU
- Malpractice (liability) RVU
These units are then transformed into dollars using a single conversion factor, updated by CMS on a yearly basis.
Understanding RVUs is important, not because physicians should practice with billing in mind, but because documentation gaps can unintentionally undervalue the work already performed.
If RVUs are assigned to each CPT code, how are the CPT codes assigned to each encounter?
For each of the encounter levels previously mentioned, except for critical care, the process for determining the appropriate CPT code assignment for an encounter involves three elements of the MDM (medical decision making):
- The number and complexity of problems addressed
- The amount and/or complexity of data to be reviewed and analyzed
- The risk of complications and/or morbidity or mortality of patient management
These are often referred to as COPA (complexity of problems addressed), Data, and Risk of Management respectively.
It is worth taking a moment to recognize that the amount of history or physical exam is no longer a factor in determining the complexity of an encounter. Although a medically appropriate history and/or physical examination is still required, the nature and extent of these activities is determined by the treating physician or other qualified health care professional reporting the service and is not an element in selection of the level of these service codes.
The three elements of the MDM are arranged into the MDM table created by the AMA. Each element is scored on this grid to determine the three individual element complexity levels. The encounter then qualifies for the overall complexity level that at least two of the three elements meet or exceed.
For emergency physicians, understanding how to document these three areas is the key to accurate coding.
The number and complexity of problems addressed (COPA) is the first MDM element and focuses on the conditions or concerns addressed during the encounter. This includes conditions ruled in as well as those actively ruled out. A useful way to think about this is the differential diagnosis, or at least those that necessitate action to evaluate further.
Again, this has moved away from final diagnoses where documenting the evaluation of possible serious conditions that were considered like pulmonary embolism, intracranial hemorrhage, or sepsis for example, would often demonstrate a highly complex COPA even when those diagnoses are ultimately excluded.
The amount and/or complexity of data to be reviewed and analyzed (Data) is the second MDM element and captures the orders and actions we undertake in our evaluation of the patient.
This includes:
- Ordering and/or reviewing of each unique test
- Obtaining necessary history from someone other than the patient (excludes interpreters)
- The review of external records
- Independent interpretation of tests (EKG, X-ray, CT, etc.)
- Discussion with external professionals
The data element is an area where clinicians frequently miss opportunities to convey their correct level of complexity. For example, being specific that the interpretation of an X-ray is not read from a report but is truly your own, will more accurately represent your work.
A simple phrase can ensure this work is captured:
“_____ interpreted by me shows…”
Similarly, conversations with consultants, case management, or other professionals outside your group or specialty support additional data complexity when documented.
The final MDM element is the risk of complications and/or morbidity or mortality of patient management. Common examples of management choices in the emergency department that are associated with risk may include:
- Management of medications and IV fluids
- Actions limited by social determinants of health
- Diagnostic testing involving radiation or IV contrast dye
- Decision regarding procedures or surgery
- Decisions regarding hospitalization or de-escalation of care
- Decisions regarding parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
It is important to understand that the AMA has listed examples of management that carry a common level of risk on the MDM table, and that these examples are not exhaustive by any means. Medicine is a practice applied to individual patients, and if a management option represents higher risk then otherwise expected due to specific aspects of a patient’s condition, it is beneficial to document these unique risks when taken into consideration. Think of fluids for a patient with heart failure for example.
So that’s CPT, but where do ICD-10 codes fit into this?
ICD-10 codes describe diagnoses, as opposed to CPT codes which describe the work performed in evaluating a patient to determine those diagnoses. This distinction is at the heart of why a patient discharged with a benign condition may still justify a high-complexity encounter. We do not base our professional fee on final diagnoses; we base it upon our work to get there. And yet, as you read this, lists of ICD-10 codes are being used by insurers across the country to downcode or deny paying appropriately for the work we have undertaken. These lists, often called LANE (low acuity non-emergent) diagnoses lists fly in the face of CPT and the many changes undertaken in the 2023 coding guidelines.
A common clinical example may include the patient presenting to the emergency department with chest pain and mild hypertension requiring extensive work-up to exclude acute coronary syndrome. Though documentation may include excellent history taking, an appropriate exam, multiple necessary laboratory studies, an EKG interpreted by the emergency clinician, a chest x-ray similarly interpreted, and discussions of various lethal concerns that were actively excluded, the only confirmed non-symptom diagnosis may eventually be an exacerbation of chronic hypertension.
If that diagnosis was the only confirmed diagnosis for the encounter, it could be denied or downcoded as “non-emergent” under these inappropriate programs. Although including the symptom diagnoses like chest pain that drive the MDM may help, it does not fix the underling error in reimbursement based upon final ICD-10 codes instead of clinical complexity.
I hope this article has set the groundwork for future articles that may delve deep into the many areas of emergency medicine documentation. Until then, please remember that strong documentation is more than a clerical task, it is a clinical skill that reflects the quality, complexity, and thoughtfulness of the care you provide.
By consistently capturing your clinical reasoning, reassessments, and decision-making, you not only tell the full story of the encounter but also reinforce the value of your work. Excellent documentation is not about writing more, it’s about writing with purpose, precision, and intent.
Photo Credit: Ivan S
