2023 Emergency Department Evaluation and Management Guidelines

The codes have not changed, but the code descriptors have been revised. In November 2019, CMS adopted the AMA’s revisions to the Evaluation and Management (E/M) office visit CPT codes (99201-99215), code descriptors, and documentation standards.  The revised CPT guidelines for office/outpatient E/M codes went into effect on January 1, 2021

On July 1, 2022, the AMA released additional revisions to the rest of the E/M code sections, including the ED E/M codes.  The 2022 revisions will provide continuity across all the E/M sections.

The revised E/M codes, descriptions, and guidelines will apply to all E/M codes on January 1, 2023.

For 2023, ED E/M definitions have been updated to correlate with the change in E/M coding guidelines to select the E/M code based exclusively on Medical Decision Making.

• 99281 - Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
• 99282 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• 99283 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
• 99284 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate medical decision making.
• 99285 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

The most significant revisions to the 2023 E/M Guidelines are:

• The elimination of history and physical exam as elements for code selection.
• E/M code selection is based on Medical Decision Making or Total Time.
  • Note that time is NOT used to select ED E/M levels of service. (See FAQ #4)
• Revisions to the rules for using Time to assign an E/M code.
• Modifications to the criteria for determining the level of Medical Decision Making (MDM).

While the history and exam don’t directly contribute to selecting the E/M code, the emergency department E/M codes stipulate that there should be a medically appropriate history and/or physical examination.  

The nature and extent of the history and physical examination are determined by the treating physician/Qualified Healthcare Professional (QHP). Importantly, the extent of history and physical exam documented is not used to assign the E/M code.

However, the MDM grid measures the complexity of problems addressed with expressive statements such as acute, uncomplicated illness or injury, undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; chronic illnesses with severe exacerbation. While the history and exam elements are not “counted,” a descriptive history and exam will ensure the coder or auditor will understand the complexity of problems addressed to the extent necessary to determine medical decision-making accurately.

Only when they are clinically relevant to the current E/M service. AMA/CPT suggests reducing links embedded in documentation templates that automatically pull in data from other parts of EHR, contributing to “note bloat” but adding little, if any, true clinical value.

• In the emergency department, time will be utilized when assigning critical care codes 99291-99292, but NOT for ED E/M codes 99281-99285. The long-standing policy for time in relation to the ED E/M codes has not changed. CPT continues to state, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”

  Of note, for 2023, observation services may be reported based on time using the revised Hospital Inpatient and Observation Care Services E/M codes 99221-99223 and 99231-99239.

  See the Observation and Critical Care FAQs for additional details regarding documentation of time for those services.

• There are minor changes to the three current MDM sub-components, but there have been extensive edits to the process of “scoring” MDM elements for code selection.
• The current CMS Table of Risk and Contractor audit tools were used as a basis for designing the revised required elements for MDM.
• The revisions removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• AMA has provided definitions for important terms, such as “Independent historian,” “other appropriate source,” etc.
• The Marshfield MDM scoring is no longer a factor; the long-standing debate of new problem vs. established problem and no additional workup vs. additional workup planned have been eliminated.
• Changes in scoring Complexity of Data Reviewed include points counted for each unique test ordered/reviewed, review of prior external notes, and history from an independent historian.
• The cognitive effort of considering testing or treatment that may not be performed is recognized as contributing to the complexity of the MDM.
• Assessing the risk vs. benefit of hospital admission is recognized as a high-risk decision, even if the patient is ultimately discharged or sent to rehabilitation or a skilled nursing facility.
• The final diagnosis is not the sole determining factor for an E/M code. Presenting symptoms likely to represent a highly morbid condition may require an extensive evaluation. These extensive diagnostic and/or therapeutic interventions to identify or rule out a highly morbid condition will determine MDM even when the ultimate diagnosis is not highly morbid.

When assigning a value to the Number and Complexity of Problem(s) Addressed (COPA), there are several factors to consider.

• The problem has been addressed when it is evaluated or treated by the physician/QHP, with or without a diagnosis established during the encounter.
• This includes consideration of further testing or treatment that may not be performed by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.
• Multiple illnesses or injuries that may be low severity as standalone presentations can increase the complexity of the MDM when combined in a single evaluation.
• Comorbidities and underlying diseases can contribute to the MDM if addressed during the encounter.
• Multiple problems of a lower severity may, in the aggregate, create higher complexity.
• The final diagnosis does not determine the complexity or risk. An extensive evaluation may be required to conclude that the signs or symptoms do not represent a highly morbid condition.
• Presenting symptoms that are likely to potentially represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid.

The MDM grid from CPT divides COPA into four levels: Minimal, Low, Moderate, or High.

Yes, the E/M guidelines offer these definitions for each of the elements:

• Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
• Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (e.g., uncontrolled diabetes and controlled diabetes are a single chronic condition).
  • "Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.
    • For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
  • Acute, uncomplicated illness or injury: A recent or new short-term problem with a low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.
    • A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
  • Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
  • Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
  • Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.
  • Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
    • Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
  • Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment.
    • Systemic symptoms may not be general but may affect a single system.
    • For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury.
  • Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.
  • Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in the level of care.
  • Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment that poses a threat to life or bodily function in the near term without treatment.
    • Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential

CPT has not published clinical examples for the COPA elements. In addition, the clinical examples for the E/M codes in Appendix C will be deleted from CPT in 2023. The ACEP Coding and Nomenclature Committee has reviewed available CPT guidelines, AMA clarifications published in CPT Assistant, and common practices in the emergency department to offer some guidance when assessing the Complexity of Problems Addressed. 

Minimal

• One self-limited or minor problem.
  • It is improbable that many patients that present to the emergency department clinically fit into this category. CPT stipulates that a problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Given this description, an illness or injury that warrants a visit to the emergency room seems to exceed what would be considered a self-limited or minor problem. Presentations in this category will most likely be limited to patients who return to the ED for uncomplicated suture removal, dressing changes, or packing removal.

Low          

• Two or more self-limited or minor problems
  • See the above description of a self-limited or minor problem.
• One stable chronic illness and
• One stable, acute illness
  • The CPT definition of “Stable” makes it doubtful that patients presenting to the department fit into these categories.

"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

A patient who presents with an illness or injury to be evaluated by the emergency physician does not fit this definition of stable. Additionally, CPT indicates these are “A problem that is new or recent for which treatment has been initiated…” which is unusual in the emergency department setting.

• Acute, uncomplicated illness or injury
  • ED presentations in this category will be limited to localized complaints that do not include additional signs or symptoms.
  • Uncomplicated injuries will be minor traumatic injuries that are appropriately evaluated without x-rays (e.g., extremity injuries with limited pain, swelling, or bruising) and can usually be managed with over-the-counter medications. Injuries that require prescription medications for more aggressive pain management or other prescription medications (e.g., antibiotics due to infection risk) are typically more consistent with an acute complicated injury.
  • Uncomplicated illnesses are minor illnesses with no associated systemic symptoms and can be evaluated without testing or imaging (e.g., isolated URI symptoms). Most of these patients can be reasonably treated with over-the-counter medications.  Illnesses that have developed associated signs or symptoms, or require testing or imaging, or necessitate treatment with prescription strength medications have progressed beyond an uncomplicated illness.
  • One acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care

For physicians and coders working in the emergency department, a patient that requires hospitalization seems out of place in the Low COPA category. AMA CPT personnel have said that this bullet was added to provide a mechanism to score Low MDM as required for the inpatient hospital/observation E/M codes.  This bullet should not be used when calculating the MDM for patients in the emergency department.

Moderate      

• Two or more stable chronic illnesses.
  • See the above explanation of stable chronic illness.
• One acute complicated injury
  • As indicated by the CPT definition, these are injuries that require an evaluation of organ systems or body areas beyond just the injury site (e.g., musculoskeletal injuries where an assessment of distal neurovascular function is indicated).
  • A patient’s mechanism of injury can also be an indication of an acute complicated injury. ED presentations prompted by a fall, MVA, fight, bicycle accident, or any other accident require the physician/QHP to evaluate multiple organ systems or body areas to identify or rule out injuries.
  • Accidents and/or injuries that necessitate diagnostic imaging to rule out significant clinical conditions such as fracture, dislocation, or foreign bodies are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity.
• One or more chronic illnesses with exacerbation, progression, or side effects of treatment.
  • Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
    • chronic illnesses with exacerbation, OR
    • chronic illnesses with progression, OR
    • chronic illnesses with side effects of treatment.
  • One undiagnosed new problem with uncertain prognosis.
  • One acute illness with systemic symptoms.
    • There are many presenting problems, chief complaints, and associated signs and symptoms that could fit into these three categories.

In response to a reader’s question, CPT Assistant indicated that abdominal pain would likely represent “at least” Moderate COPA. This could be a patient with chronic abdominal pain, so the presentation would be considered a chronic illness with exacerbation. It may be a patient with no history of abdominal pain that would be an undiagnosed new problem with uncertain prognosis. Or it might present as abdominal pain with vomiting and diarrhea, so it would score as an acute illness with systemic symptoms. 

This concept can be applied to many evaluations for patient complaints that should be considered at least Moderate COPA. The following are some examples, but this is not an all-inclusive list:

It is important to recognize that all of these presentations exist within a clinical spectrum of severity. At the moderate level, diagnostic evaluations for these would likely involve simple testing, such as plain x-rays or basic lab tests. 

• Systemic symptoms may involve a single system or more than one system. Presentations representing two or more systems seem to exceed a single acute uncomplicated illness or injury, suggesting at least a moderate COPA. CPT states, “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
• Fever is generally considered to likely represent a systemic response to an illness. CPT states that fever associated with a minor illness that may be treated to alleviate symptoms is more typical of an uncomplicated illness. For example, an otherwise healthy patient with a fever solely associated with uncomplicated viral URI symptoms is a less concerning clinical process. However, fever or body aches not associated with a minor illness or associated with illnesses that require ordering a test or prescription drug management may represent a broader complexity of problem being addressed or treated.
• Regardless of final diagnosis, accidents and/or injuries that necessitate diagnostic imaging to identify or rule out a clinical condition such as a fracture, a dislocation, or a foreign body are indicative of a potentially extensive injury with multiple treatment options and risk of morbidity and consistent with an undiagnosed new problem with uncertain prognosis.
• As part of an evaluation a physician/QHP may order or review an advanced laboratory test or other complex diagnostic study (e.g., Troponin, BNP, D-Dimer, Lactate, CT, US, MRI etc.) or obtain a consultation or consider escalation of care. Such evaluations are typically for a patient presenting with complaints or symptoms consistent with a potential condition that poses a threat to life or bodily function. In such cases, the encounter has likely surpassed a moderate COPA presentation.

High

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
  • Stylistically, this element is listed as above in the MDM table, but it should be interpreted as:
    • chronic illnesses with severe exacerbation, OR
    • chronic illnesses with severe progression, OR
    • chronic illnesses with severe side effects of treatment.
  • One acute or chronic illness or injury that poses a threat to life or bodily function
    • Presenting problems in these High COPA categories are high-risk presentations where the physician/QHP is evaluating or ruling out a condition with a significant risk of morbidity or one that poses a threat to life or bodily function. These are patients with symptoms that potentially represent a highly morbid condition and therefore support high MDM even when the ultimate diagnosis is not highly morbid.   

The final diagnosis for a condition, in and of itself, does not determine the complexity of the MDM. The presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, may indicate that an extensive evaluation is required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

The following high COPA examples may be demonstrated by the totality of the medical record as demonstrated implicitly by the presenting problem, or diagnostic evaluation, or treatment or management, or differential diagnoses, or overall medical decision making, as demonstrated in the entire record.

This is not an all-inclusive list; high COPA should be considered for evaluations of patients with presentations potentially consistent with, but not limited to:

It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity.

Yes, physicians may be cautioned against documenting possible, probable, or rule-out diagnoses because these conditions cannot be used for ICD-10 coding in the emergency department, other outpatient settings. However, these rule-out conditions illustrate the significance of the complexity of problems addressed and justify the work done, especially in situations where the final diagnosis seems less than life-threatening. Per CPT:

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. Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition.

Yes, the physician/QHP may employ risk stratification tools to ascertain the significance or severity of a presentation and/or help determine appropriate diagnostic or therapeutic interventions. Some tools that may be relevant to emergency medicine are:

• Canadian CT Head Injury rule – Calculates the need for a CT for patients with a head injury.
• HEART score – for major cardiac events and to determine between discharge or admit/obs from the ED
• NEXUS and Canadian c-spine rule to out potentially disabling c-spine injury.
• Ottawa Ankle and Knee Rule - Calculates the need for an x-ray for patients with an ankle/knee injury.
• PECARN for Pediatric Head Injury - Predicts need for brain imaging after pediatric head injury.
• PERC Rule For Pulmonary Embolism - Rules out PE if no criteria are present and pre-test probability is ≤15%.
• Pneumonia Severity Index / PORT score – Estimates mortality for adult patients with community-acquired pneumonia and determines between discharge or admit/obs from the ED
• Well’s Criteria for DVT - Calculates risk of DVT based on clinical criteria
• Well’s Criteria for Pulmonary Embolism - Objectifies risk of pulmonary embolism.

Documentation that the physician/QHP used a risk calculator to determine the need for additional testing or treatment is an indicator of the complexity of problems addressed. 

When a risk calculator score has suggested that a diagnostic test is not indicated, the Data Category 1 element should be scored the same as if the test had been ordered, as indicated by the CPT statement, “Ordering a test may include those considered but not selected.”

Simply listing the comorbidity does not satisfy the CPT definition.  The documentation should reflect how the comorbidities impacted the MDM for the ED encounter. Per CPT, “Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”

Pregnancy in a patient can significantly impact the complexity of presenting problems and the risk associated with treating the patient, even when the chief complaint is not directly related to the pregnancy. This is primarily due to the physiological and anatomical changes that occur during pregnancy, which can influence the management and outcomes of various medical conditions.

Pregnancy is associated with a multitude of physiological changes that can affect the presentation and management of non-pregnancy-related medical conditions. For example, the cardiovascular system undergoes significant adaptations to support the growing fetus, including increased blood volume, cardiac output, and changes in vascular resistance. Pregnancy also predisposes the patient to hypercoagulability and ligament laxity. The physiology of pregnancy can complicate the evaluation and treatment of Emergency Department patients. It may include conditions such as hypertension, pre-eclampsia/eclampsia/HELLP syndrome, cardiac arrhythmias, dissections, and pulmonary embolism. These factors can also affect the body’s reaction to trauma.

Additionally, pregnancy can influence the interpretation of diagnostic tests and imaging studies. Hormonal changes during pregnancy can affect laboratory values, making it essential for healthcare providers to consider pregnancy-specific reference ranges when interpreting test results. Furthermore, the presence of an enlarged uterus can impact the accuracy and interpretation of signs and symptoms of diseases such as trauma, appendicitis, renal colic, and pyelonephritis, as well as imaging studies, potentially leading to diagnostic challenges or the need for additional investigations.

Moreover, the potential risks associated with treating a pregnant patient must be carefully considered. Medications and interventions that are typically safe for non-pregnant individuals may have adverse effects on the developing fetus. Healthcare providers must exercise caution when prescribing medications, ensuring the safety of both the mother and the unborn child. Additionally, certain diagnostic procedures, such as radiation-based imaging or invasive interventions, may carry increased risks to the fetus and require careful consideration of the potential benefits and harms.

Any pregnant patient presenting to the ED with an illness or injury could reasonably be considered at least moderate COPA. Assigning high COPA would be appropriate if the illness or injury poses a potential threat to the mother or fetus.

Many diagnostic tests performed in the ED carry a potential risk of causing fetal distress or premature labor, especially if performed in high-risk conditions such as placental insufficiency or preeclampsia. Additionally, certain imaging studies such as non-extremity X-rays, CT scans, and VQ scans carry a higher risk due to the potential harm from radiation exposure, particularly during the first trimester when organogenesis is occurring.

The decision to order (or defer) these types of diagnostic tests is an element of the amount and/or complexity of data. The risk associated with the performance of the test would be classified as high in the risk column when choosing the E/M level of service.

In addition, some medications, especially medications classified as pregnancy category C, D or X, have been identified as potentially harmful to a fetus and should be avoided or used with extreme caution in pregnant patients, which is more consistent with a high-risk management decision.

Establishing a differential diagnosis involves systematically considering multiple potential causes for a patient's presenting signs and symptoms. This process requires an evaluation of the patient's medical history, a physical examination, and formulating a list of possible diagnoses. Each potential diagnosis is further refined or ruled out based on additional information or diagnostic tests.

The choice of which diagnostic tests to order is based on the patient's clinical presentation and suspected underlying conditions. In some cases, the differential diagnosis may not be explicitly documented by the physician/QHP but implied by the diagnostic tests ordered by the physician/QHP. In such situations, another physician would understand the type and severity of the potential diagnosis being investigated by reviewing the diagnostic workup ordered during the emergency department evaluation. An experienced coder/auditor should be able to do the same.

Certain diagnostic tests can be suggestive of specific conditions. For instance, ordering an x-ray for a patient with wrist pain after a trip and fall may indicate a differential diagnosis of wrist fracture or dislocation. Similarly, ordering a head CT scan after a patient sustains a blow to the head suggests that the emergency department physician is investigating the possibility of an intracranial injury. In cases where a patient presents with chest pain, the ED physician may order an electrocardiogram (EKG) and a troponin lab test, as they are vital tools in evaluating patients with suspected cardiac events and help confirm or rule out a heart attack or other acute coronary syndromes.

In the absence of a documented differential diagnosis, it is imperative for coders and auditors to understand the significance of the various diagnostic tests and their implications for the potential diagnosis being considered.

Amount and/or Complexity of Data to be Reviewed and Analyzed (Data) is divided into three categories:

• Category 1: Tests, documents, orders, or independent historian(s).
• Category 2: Independent interpretation of tests (not separately reported).
• Category 3: Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source.

The MDM grid in the E/M section of CPT assigns value to components of the Data categories. For each encounter, elements from each category are counted to determine if the Data is Minimal, Limited, Moderate, or Extensive.    

Each unique test, order, or document is individually counted to meet the indicated requirement for each level of Data. A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian, would be a combination of three elements.

• Review of prior external note(s) from each unique source.
  • External notes are any records, communications, test results, etc., from an external physician/QHP, facility, or health care organization. For the emergency physicians, these will be any notes that come from outside their emergency department, e.g., inpatient charts, nursing home records, EMS reports, ED charts from another facility or ED group, etc.
  • A unique source is defined as a physician/QHP in a distinct group, different specialty, subspecialty, or unique entity.
    • Medical records from prior visits to the same emergency department do not qualify as external records as they are from the same physician group/specialty.
  • Review of external notes from each unique source counts as one element when calculating the Data, e.g., a review of a discharge summary from a prior inpatient stay and review of nursing home records would each count as 1, for a total of 2 “points” for Category 1.

• Review of the result(s) of each unique test.
  • Tests are imaging, laboratory, psychometric, or physiologic data.
  • The CPT code set defines a unique test.
  • A clinical laboratory panel, e.g., BMP (80047), is a single test.
  • When the same test is performed multiple times during an ED visit (e.g., serial blood glucose, repeat EKG), count it as one unique test.
  • For data reviewed and analyzed, pulse oximetry is not a test. Pulse oximetry is now considered a vital sign.

• Ordering of each unique test.
  • Ordering a test is included in reviewing the results.
  • A single unique test ordered or reviewed is a data point, but a single unique test ordered and reviewed is not 2 points.
  • It is assumed that the physician/QHP will review the results of a test ordered; therefore, the physician/QHP does not receive dual credit in Category 1 for both ordering and reviewing the same test.
  • Review of a test ordered by another physician counts as a review of a test. For example, a review of tests performed at an outside clinic, urgent care center, or nursing home prior to arrival in the ED would qualify.

• A combination of different Category 1 elements are summed to determine the total.
  • A lab test ordered, plus an external note reviewed and an independent historian would be a total of three for Category 1 under moderate or extensive data.
  • All the Category 1 value can come from a single bulleted element.
  • Ordering an EKG (93010), a CBC (85027), and a CMP (80053) is a total of three for Category 1, even though they are all from the same element (Ordering of each unique test).
  • Ordering a CBC, CMP, and cardiac troponin is a total of three for Category 1, even though they are all lab tests, as each test has a unique CPT code.

The primary concern for any documentation in the medical record should be to ensure that the patient's record accurately represents the patient's clinical condition and treatment in the ED. The physician/QHP should document any information they feel is clinically relevant to the evaluation and management of the patient.

Many opinions and coding policies are based on language from the CMS 1995 E/M guidelines (Relevant findings from the review of old records should be documented) or the Marshfield Clinic E/M scoring tool (Review and summarization of old records). These coding policies were retired as of January 1, 2023, with the adoption and implementation of the 2023 E/M Guidelines by CPT and CMS. 

Neither CPT nor CMS policy indicate a documentation standard for counting Category 1 data elements. In the preamble to the E/M guidelines, CPT states, "These guidelines do not establish documentation requirements."

In response to a reader question regarding using “outside records reviewed” without any analysis or summary to qualify for data, the December 2022 issue of CPT Assistant indicated that the notation “outside records reviewed” should be counted as Category 1 data credit, with the provision that the review is used in the MDM during the current E/M service. 

Yes, the PDMP contributes to the MDM as it allows the physician/QHP to see patients’ prescribing histories to assist in making their prescribing decisions.

It depends on the Data level.  For Limited data, it is Category 2; for Moderate and Extensive, it is included in Category 1.

• Any individual (e.g., EMS, parent, caregiver, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient.
• The independent historian should provide additional information and not merely restate information already been provided by the patient unless confirmation is necessary.
• The physician/QHP may query an independent historian when the patient is unable to provide a complete or reliable history for any reason, e.g., developmental stage, mental status, clinical urgency.
• The physician/QHP may query an independent historian when a confirmatory history is judged to be necessary.
• In cases in which the patient cannot provide any information (e.g., developmental age), the independent historian may provide all of the required information.
• The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
• Independent historian does not include translation services.

Coding policy based on the CMS 1995 E/M Documentation Guidelines statement “the record should describe the patient's condition or other circumstance which precludes obtaining a history” does not apply to patients treated after January 1, 2023. 

CPT 2023 indicates the physician/QHP may utilize an independent historian when they cannot get reliable history from the patient or need to confirm the accuracy of the history obtained from the patient. The physician/QHP may involve an independent historian in the E/M service when clinically appropriate during patient treatment. CPT does not require the physician/QHP to document the reason that an independent historian was utilized during the evaluation of the patient. Nor does CPT require that the physician/QHP document which elements of the history were obtained from the independent historian.            

CPT Assistant November 2020 / Volume 30 Issue 11 does indicate that all of the history may be obtained from the independent historian in cases where the patient cannot provide any information.  At a minimum, the physician/QHP should document the source of any history obtained from anyone other than the patient. The documentation style or format in which the independent historian is identified (e.g., “history per the mother,” “Additional history from spouse,” etc.) is at the discretion of the treating physician/QHP or may be determined by health record format or hospital/physician group policy.

In most cases, EMS would be considered an independent historian in Category 1. Discussions with EMS primarily focus on obtaining a comprehensive history of the patient's condition. Gathering information about the presenting complaint, medical history, accident details, and other relevant events leading up to the emergency department would all be considered additional history from an independent historian.

• Any interpretation of a test for which there is a CPT code, and an interpretation or report is customary.
• In the emergency department, examples include X-ray, EKG, ultrasound, CT scan, and rhythm strip interpretations.
• A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
• If the CPT code for the independent interpretation is separately reported, it cannot also be counted in Category 2.

No, per CPT, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.”

Yes, the order for a test that is not separately reported may be counted in Category 1. When documented, the independent interpretation of the same test may also be counted in Category 2.

• No, Category 2 only applies for interpreting a test where an interpretation or report is customary, e.g., EKG, X-ray, ultrasound, rhythm strip. Lab tests do not have a separate interpretation component.
• Per CPT, “Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.”

Yes, in the definition of the amount and/or complexity of data to be reviewed and analyzed, the E/M guidelines stipulate that ordering a test may include those considered but not selected. CPT does require that “the considerations must be documented”; therefore, the physician/QHP documentation should indicate how/why they arrived at the decision to forego the order for the diagnostic test.

Yes, comparing recent x-ray findings to a previous x-ray would be considered an independent interpretation.

• Discussion requires an interactive exchange.
• The exchange must be direct and not through nonclinical intermediaries.
• Sending chart notes or written exchanges within progress notes do not qualify as an interactive exchange.
• It may be asynchronous; it does not need to be in person.

• Any external physician/QHP who is not in the same group practice or is of a different specialty or subspecialty within the same group.
• It may also be the staff of a facility or organizational provider such as a hospital, nursing facility, or home health care agency.
• An appropriate source are professionals who are not health care professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher).
• Appropriate source does not include discussion with family or informal caregivers.

For the purposes of determining medical decision-making, the chart should indicate that the ED physician/QHP had an interactive exchange (e.g., in-person or via telephone, text, secure electronic messaging, etc.) with another physician/QHP from a different practice or specialty or other professional involved in the management of the patient. Category 3 discussions may be asynchronous, but they should be completed in a timely manner (e.g., within a day or two) and contribute to the MDM of the current E/M service.

The documentation style or format in which the external physician/other appropriate source is identified (e.g., “discussed with cardiology” vs. “discussed with Dr. Smith,” etc.) and the discussion details (e.g., "recommended a repeat troponin and EKG in two hours" or “will accept admission”) are at the discretion of the treating physician/QHP. Documentation content requirements are an internal hospital or physician group decision.

Coding policies based on the Marshfield Clinic E/M scoring tool data point “Review and summarization of discussion of case with another health care provider” were retired as of January 1, 2023, with the adoption and implementation of the 2023 E/M Guidelines by CPT and CMS. 

Yes, the DGs state that external discussions can be with “a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.” The physician/QHP discussing consultations, transfer details, admit orders, post-ED patient management, etc., are all clinically relevant discussions contributing to the MDM and should be counted as Category 3.

Yes, the decision to order the test (Category 1) is a separate and distinct element from discussing the films/images with the radiologist (Category 3).

• The assessment of the level of risk is affected by the nature of the event under consideration.
• A low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk.
• Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.
• Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk. They do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).
• For the purpose of MDM, the level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.
• The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
• Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.

The MDM grid in the E/M section of CPT assigns value levels of Risk.  For each encounter, patient management decisions made by the physician/QHP are assessed as Minimal, Low, Moderate, or High.   

When asked for clarification or additional examples, AMA/CPT indicated that it would be impossible to list all the possible patient management decisions in the MDM grid. And that the examples listed in the risk column are not exhaustive and may not be the only patient management decisions to be taken into account when establishing the level of risk when calculating the E/M service.

The 2023 E/M Guidelines indicate that physicians/QHPs have a common understanding of how diagnostic and therapeutic decisions made in the patient management process can be categorized as high, medium, low, or minimal risk. And while they are not required to quantify their definition, the assignment of risk should be based on the usual behavior and thought processes of a physician/QHP from the same specialty.

There are no published examples of minimal or low risk from diagnostic testing or treatment rendered.

This question has been posed to the AMA/CPT; in the November 2020 issue of CPT Assistant, it was clarified that MDM should focus primarily on physician/QHP work performed and decisions made during the E/M encounter. The issue explained that the MDM process has been revised, and prior MDM scoring elements may not accurately represent risk with the new MDM process.

While the 2023 E/M Risk Column may provide a reference for determining the level of risk associated with certain decisions, it is important to note that via CPT Assistant and other documents, AMA/CPT has indicated that the bulleted risk items are only examples of management options.

While the items listed in the Risk column may be used as a starting point, the level of risk associated with any medical procedure or treatment can vary depending on the individual patient's medical history, current health status, and patient management decision during the current E/M encounter.

While minor surgery, over-the-counter medications, etc., may be considered low risk in some patients, there are situations where these decisions carry a higher level of risk due to the patient's medical history or other factors. Even minor surgeries can carry a higher risk level for patients with certain medical conditions such as diabetes, heart disease, a weakened immune system or when taking anticoagulation. In these cases, the patient may be more susceptible to infection or complications during and after the procedure.

Yes, the decision that the patient needs the diagnostic test is an element of the amount and complexity of data. The risk associated with the performance of the test would be considered in the Risk Column when choosing the E/M level of service.

Performing nasopharyngeal or oropharyngeal swabs is a routine procedure to collect samples for diagnostic testing, particularly in cases where respiratory infections such as strep throat, influenza or COVID-19 are suspected. While inherent risks are associated with any medical procedure, the risks associated with performing throat or nasal swabs have a low risk of complications and/or morbidity.

The most common risks associated with throat or nasal swabs include patient discomfort, gagging, and irritation of the nasal or throat passages. In general, these risks are typically short-lived and resolve quickly. In rare cases, there may be minor bleeding or infection at the site of the swab. Very rarely, there can be significant trauma.

Yes, while the order for the diagnostic test is counted in the data column, the risk associated with the blood draw would be considered in the Risk Column when choosing the E/M level of service.

Venipuncture, the process of entering a vein to obtain a blood sample or for the initial placement of an IV catheter (not giving IV medications or fluids), is commonly performed in the emergency department. While performing venipuncture as part of an ED visit carries some inherent risks, these risks are generally low and can be mitigated by following proper protocols and guidelines. These risks can vary depending on various factors, such as the patient's medical condition or past medical history.

One of the primary risks associated with venipuncture is infection. Although healthcare providers follow strict protocols to minimize the risk of infection, there is still a possibility of introducing bacteria into the bloodstream. This can lead to local infections at the puncture site or, in rare cases, systemic infections such as sepsis.

Another potential risk is a hematoma or a superficial clot in the vein (also known as superficial thrombophlebitis) formation. During the procedure, there is a small chance of inadvertently damaging the surrounding tissues, leading to bleeding and the formation of a hematoma or clot formation, leading to thrombophlebitis. This can cause discomfort and bruising and, in rare cases, may require further medical intervention.

Additionally, there is a small risk of nerve injury during venipuncture. If the needle inadvertently comes into contact with a nerve, it can result in temporary or, in rare instances, permanent nerve damage.

The risks associated with venipuncture and IV insertion are generally consistent with a low risk of complications and/or morbidity.

While there are potential risks involved, the risks associated with removing sutures or packing from a well-healed wound are usually minimal, and complications are rare.

The primary concern is the risk of infection, although this risk is minimal if proper aseptic technique is followed.

In rare cases, minor bleeding or discomfort may occur during removal, but these complications are generally easily managed.

Similarly, removing packing from a wound or nasal packing is generally considered a minimal risk procedure. The main concern is the potential for bleeding or injury to the surrounding tissues.

While this type of follow-up care usually carries minimal risk, it is essential to note that the risk may vary depending on several factors, including the type and severity of the wound, the patient’s overall health condition, and any underlying medical conditions or medication use. When there are increased risks of infection or complications associated with the wound, the ED physician may have to repack the wound or prescribe antibiotics for infection. These complications would elevate the patient's management decisions beyond minimal risk.

The level of service can vary depending on several factors, including but not limited to the patient’s medical history, the acuity of their condition, and the complexity of the patient’s work requirements.

When a patient presents to the ED without any active signs or symptoms requesting a work release due to employer requirements for a "doctor's note," the ED physician typically conducts a brief history and/or examination and issues a work release. This type of encounter, where the patient is deemed healthy, asymptomatic, and capable of returning to work without any limitations, is reasonably classified as minimal COPA and minimal risk.

However, if the patient is still experiencing signs or symptoms that necessitate evaluation and/or treatment, or if the physician needs to assess the inherent risk of the previous injury, potential for symptom recurrence or reinjury, and implement work restrictions, the complexity of the presenting problem and the level of risk will likely be higher. In such instances, the COPA and risk will likely exceed what would be considered minimal.

Prescription drug management is based on documentation that the provider has administered, prescribed, or evaluated current medications during the ED visit. This may be any administration of prescription strength medication while the patient is in the ED (e.g., oral meds, IM injections or IV injection/infusion), a prescription written to be filled at the pharmacy, discontinuation or modifications to the patient’s existing medication dosages, or after consideration of the current medications, the decision to maintain the current medication regimen.

Yes, when assigning risk for medications, the risk level is determined by the medication given, the dosage prescribed, and patient specific risk factors.

Per AMA/CPT, there is no blanket guidance categorizing medications into specific levels of risk. While the MDM grid lists prescription drug management as a moderate risk element, multiple AMA/CPT citations indicate that a medication can be low, moderate or high, depending on patient-specific factors and the associated risks typically seen with the medication. The AMA/CPT webinar E/M 2023: Advancing Landmark Updates explained, “An OTC NSAID in a person with kidney disease or on anticoagulants is of greater concern than most prescription drugs.”

The prescription dosage for many medications can vary depending on the patient’s age, weight, and medical condition. For example, the physician/QHP may instruct a patient with an acute uncomplicated illness or injury to take an OTC dosage, such as 400 mg of ibuprofen. In contrast, a higher risk patient with a more complex illness, injury, symptom, etc., may require a prescription dose of ibuprofen (e.g., >400mg).

For pediatric patients, many over-the-counter medications require clinician direction based on age/weight and/or comorbidities; the risk for these patient management decisions for pediatric patients would be consistent with moderate risk as the package insert recommendation is to consult a physician. For example:

• Acetaminophen (Tylenol) for patients under 24 months.
• Ibuprofen (Motrin) for patients under 6 months.
• Diphenhydramine (Benadryl) patients under 6 years old.

Yes. Although adverse reactions to a tetanus shot may be rare, as with most medications, the possibility of side effects does exist, mild side effects such as redness and swelling at the injection site, body aches, headaches, or tiredness are the most commonly reported. However, some patients may experience more severe adverse reactions such as fever, nausea, vomiting, diarrhea, rash, or swollen glands. In some cases, a tetanus shot may cause severe pain and/or swelling, a severe allergic reaction, or other side effects that require additional medical evaluation and treatment.

Before administering a tetanus shot, the ED physician must screen patients for complications they may have experienced after a previous tetanus vaccination. Patients with a history of allergic reactions, severe pain, swelling, or seizures may not be candidates for a tetanus shot. Patients with chronic conditions or a history of nervous system conditions may have a higher risk of side effects from a tetanus vaccine.

Patients cannot get tetanus shots off the shelf at the local pharmacy. Tetanus vaccines are not available without a prescription and require formal FDA approval. In short, the tetanus vaccine requires a doctor’s order/prescription. It is a parenteral medication (given by injection). Both factors suggest that a tetanus shot exceeds treatment decisions that are usually considered Low Risk. 

The decision to administer a tetanus vaccination is consistent with a Moderate Risk treatment decision.

Yes. Injectable lidocaine, such as that used during a laceration repair or other procedure, is not available over the counter and requires a prescription/physician direct order and thus supports prescription drug management and moderate risk. In contrast, low-strength lidocaine patches and creams do not require a prescription and are available over the counter. Injectable lidocaine carries meaningful risks, including damage to the surrounding anatomic structures, intravascular injection, seizures, arrhythmia and dysrhythmias.

• The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians.
• These terms are not defined by a surgical package classification.

The determination that a procedure is minor vs. major or has risk factors is at the discretion of the physician/QHP performing the service.  Risk for any procedure depends on the specific patient-risk factors and circumstances as they are assessed by the physician/QHP. While a procedure may be deemed high risk for a patient because of their specific circumstances, the same procedure may be assessed as moderate or low risk for a different patient. For procedures assessed as low risk, they may qualify as moderate risk if local anesthesia e.g., lidocaine is utilized (see Question 46 above)

Examples of patient risk factors that would be considered at least moderate risk may be a patient with a chronic condition (e.g., diabetes mellitus), or a patient taking medication, (e.g., anticoagulant), that may increase the risk of the procedure or affect the patient’s recovery.

Examples of procedure risk factors that would be considered at least moderate risk may be emergent/urgent procedures treating conditions that involve significant or complicated integumentary disruption (e.g., deep or contaminated laceration repair or complicated abscess treatment) or rigid immobilization of musculoskeletal injuries.

• An elective procedure is typically planned in advance, e.g., scheduled for weeks later.
• An emergent procedure is typically performed immediately or with minimal delay.
• Both elective and emergent procedures may be minor or major procedures.

• Risk factors associated with a procedure may be specific to the procedure or specific to the patient.
• An otherwise low-risk procedure on a patient with an underlying condition that increases the risk of a poor outcome could be considered moderate or even high risk.
• The physician/QHP may use evidence-based risk calculators when assessing patient and procedure risk, but it is not required. (see question 11 for examples of ED-relevant risk calculators)

Any economic or social condition such as food or housing insecurity that may significantly limit the diagnosis or treatment of a patient’s condition (e.g., inability to afford prescribed medications, unavailability or inaccessibility of healthcare). Common social determinants of health (SDOH) in the emergency department may include homelessness/undomiciled, unemployed, uninsured, and alcohol or polysubstance abuse.

Diagnosis or treatment of patients in the emergency department may be limited by various social determinants of health identified with an ICD-10 code. ICD-10 groups SDOH into categories, ED relevant SDOH, may include but are not limited to:

• Problems related to education and literacy, e.g., Z55.0 - Illiteracy and low-level literacy
• Problems related to employment and unemployment, e.g., Z56.0 - Unemployment, unspecified
• Occupational exposure to risk factors, e.g., Z57.6 - Occupational exposure to extreme temperature
• Problems related to housing and economic circumstances, e.g., Z59.0 - Homelessness or Z59.6 - Low income
• Problems related to social environment, e.g., Z60.2 - Problems related to living alone
• Problems related to upbringing, e.g., Z62.0 - Inadequate parental supervision and control
• Other problems related to primary support group, including family circumstances, e.g., Z63.0 - Problems in relationship with spouse or partner

The medical record should reflect when the diagnosis or treatment is significantly limited by social determinants of health. However, the SDOH is NOT required to be listed as part of the final diagnosis. The ICD-10 code is NOT required to be coded on the claim. 

No, a language barrier is not included on the list of SDOH conditions published by the Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), or International Classification of Diseases (ICD-10).

Furthermore, hospitals and healthcare providers that receive federal funds (e.g., Medicare or Medicaid payments) are required to provide language assistance services, including translators when required to communicate with the patient and/or their family.  Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) and Section 1557 of the Affordable Care Act (ACA) all address a physician’s responsibility to ensure effective communication with individuals who are deaf, hard of hearing or have limited English proficiency (LEP). 

• It should be noted that discussions via a translator cannot be considered an independent historian or Category 3 discussion in the data element.

• The mere presence of an issue is not the determining factor.
• The risk table stipulates, “Diagnosis or treatment significantly limited by social determinants of health.”
• The documentation should indicate how the SDOH was relevant to the diagnosis and treatment of the patient through one of the mechanisms addressed above.

Yes, the decision that the patient needs a CT scan (and the independent interpretation when applicable) are elements of the amount and complexity of data. The risk associated with the performance of the test would be considered in the Risk Column when choosing the E/M level of service. This is supported by CMS MAC references at the following links: Noridian and FCSO. 

Yes. CT scans are a common diagnostic tool in emergency medicine for the evaluation of traumatic injuries, abdominal pain, and other serious and potentially life-threatening medical conditions. However, ionizing radiation in CT scans poses a potential risk to patients. The most significant risk associated with radiation exposure from CT scans is the potential for increased cancer risk. Ionizing radiation can cause damage to DNA and other cellular structures, which can lead to the development of cancer over time.

The risks associated with radiation exposure from CT scans are higher in children than adults, and the risk increases with the number of CT scans a patient receives. The potential risks include an increased risk of cancer, particularly leukemia and brain tumors. In addition, radiation exposure can also cause damage to the thyroid gland, leading to thyroid cancer or other thyroid disorders. In rare cases, radiation exposure from a CT scan can cause skin damage, including redness, blistering, and peeling. Pediatric patients are more susceptible to radiation exposure than adults due to their developing organs and tissues. The ED physician must weigh the risks and benefits of each scan, consider alternative diagnostic tools, and take steps to minimize radiation exposure to patients, particularly in pediatric patients.

When compared to the published examples of Moderate Risk, the radiation exposure and other potential complications seem consistent with Moderate Risk.

Due to the risks associated with ionizing radiation limiting radiation exposure is an important clinical consideration. Limiting patient exposure to radiation is part of the Quality Program directives from CMS. Radiation exposure is measured in millisieverts (mSv). According to the International Atomic Energy Agency a typical person is exposed to 2.4 mSv per year or 0.2 mSv per month.   Based upon data from the American College of Radiology a typical Head CT exposes a patient to 1.6 mSv.

Plain X-rays vary greatly in the amount of radiation exposure that the patient experiences.  Below are examples of the differences in radiation between some X-rays.

• Common Extremity x-ray 0.001mSv: 3 hours of background radiation
• Chest x-ray 0.1 mSv: 2 weeks of background radiation
• Lumbar Spine x-ray 1.4mSv: 6 months of background radiation

The risks associated with simple extremity radiation are mild compared with the larger amount of radiation associated with a chest X-ray, lumbar spine, and other more anatomically centralized X-rays, which carry a minimum of 100 times the amount of radiation of a simple extremity series and may equate to 6 months of background radiation and as much as a head CT.  As such, anatomically centralized x-rays (e.g., lumbar spine, chest) have more relative radiation and are thus more consistent with moderate risk when compared to the more limited amount of radiation associated with simple extremity x-rays (e.g., ankle, wrist, forearm).

Yes. Additionally, some patients may have medical conditions that increase the risk further, or the IV fluid may include additives that reflect a higher degree of risk.

Administering IV fluids is a common and necessary intervention in the emergency department and must be ordered by a physician/QHP. However, there are some risks associated with this procedure that need to be taken into account.

One of the most common risks is infection. IV fluids are administered through a catheter inserted into a patient's vein, which can introduce bacteria into the bloodstream and cause infections. Another risk associated with IV fluids is fluid overload. In some cases, patients may receive too much fluid too quickly, leading to fluid overload and potentially life-threatening complications such as pulmonary edema. In rare cases, patients may also experience allergic reactions to the fluids or medications administered through the IV. To prevent this, it is important to monitor patients closely and adjust the rate of fluid administration as needed. Incorrect IV fluid concentration and rate choice can lead to life-threatening under or over-correction of electrolyte abnormalities or acid-base status. (e.g., sodium, chloride, potassium, calcium, and lactate).

While some risks are associated with administering IV fluids in the emergency department, these risks can be minimized by following proper protocols and monitoring patients closely. The benefits of administering fluids usually outweigh the risks, and this intervention can be lifesaving in many cases.

Compared to the published examples of moderate risk, the risks associated with IV access and administering fluids, which require a physician/QHP order in the ED, seem consistent with other examples of moderate risks, such as prescription drug management.

In the ED, splinting and casting are frequently used to treat fractures, dislocations, and other orthopedic injuries. These methods are essential to stabilize the limb to prevent further injury, reduce pain and promote healing.  But they are not without potentially disabling complications. The primary risks associated with rigid musculoskeletal immobilization include:

• Compartment Syndrome: The application of a rigid immobilization device can increase the risk of compartment syndrome, especially if the immobilization is too tight or if there is subsequent swelling within the confined space of the cast or splint.
• Pressure Ulcers: Immobilization devices that are incorrectly applied or inadequately padded can lead to pressure ulcers, particularly over bony prominences.
• Joint Stiffness and Muscle Atrophy: Prolonged immobilization can contribute to joint stiffness and muscle atrophy.
• Deep Vein Thrombosis (DVT): Immobilization of a limb can predispose patients to venous stasis and the development of DVT.
• Thermal Injury: The exothermic reaction during the setting of certain casting materials can cause burns if not properly managed.

Compared to the published examples of risk, the risks associated with rigid musculoskeletal immobilization in the ED is most consistent with at least a moderate Risk for CPT’s Medical Decision Making element “Risk of Complications and/or Morbidity or Mortality of Patient Management”.

These are encounters where the patient has been given a medication that has the potential to cause serious morbidity or death and must be monitored for adverse effects. 

Monitoring for adverse effects should be a generally accepted practice for the medication and may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify.

CPT has not published a list of “high-risk” medications. The AMA’s position is that trained clinicians understand specific patient and drug factors and know when a medication is high risk depending on the patient situation. CPT expects the physician/QHP to rely on their clinical judgment to determine which medications are at higher risk of morbidity or, in some cases, mortality for a particular patient.

The CMS MAC for Jurisdiction J (Palmetto) has published a list of examples, but many of the meds listed are not typically used in the emergency department. Their list can be found here.

The below list is not all-inclusive but provides examples of ED-relevant medications that could cause serious morbidity or death and may be monitored for adverse effects:

During pregnancy, it is crucial to carefully consider the use of any medication, as certain drugs can have harmful effects on the developing fetus. The U.S. Food and Drug Administration (FDA) has established a system to categorize medications based on their potential risks during pregnancy. The categories range from A to X, with Category A being the safest and Category X indicating the highest risk.

• Category C medications are those for which there are limited human studies available, and the potential risks to the fetus cannot be ruled out. This means that there is a possibility of adverse effects on the developing baby.
• Category D pregnancy medications refer to drugs that have been classified by the FDA as having potential risks to the fetus. These medications should only be used if the potential benefits to the mother outweigh the potential risks to the unborn baby. It is important to note that the classification of a medication into Category D does not necessarily mean that it will cause harm to every fetus exposed to it.
• Category X pregnancy medications refer to medications that are contraindicated during pregnancy due to their potential risks and harm to the developing fetus. These medications have the potential to cause birth defects, developmental delays, miscarriage, or even fetal death.

Some examples of high-risk medications in pregnancy include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs such as ibuprofen and naproxen should be used sparingly during pregnancy, especially during the third trimester. Prolonged use of these medications can increase the risk of complications, including premature closure of the fetal ductus arteriosus and impaired kidney function. NSAIDs are classified as category B in the first and second trimesters and category D in the third trimester.
• Anticoagulants: While anticoagulants like warfarin are essential for some patients, they pose a significant risk to the developing fetus. These medications can cross the placenta and potentially cause birth defects or bleeding complications. Pregnant patients requiring anticoagulation therapy are often switched to safer alternatives like heparin or low molecular weight heparin, which remains high risk as a category C.
• ACE inhibitors and ARBs: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are commonly used to manage hypertension and other cardiovascular conditions. However, these medications can cause fetal harm, including kidney damage and growth restriction. Alternative medications should be prescribed to pregnant patients. ACE and ARBs are classified as Category C in the first trimester and Category D in the second and third trimesters.
• Antidepressants: Certain antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), fall under Pregnancy Category D. They have been linked to potential risks, including an increased risk of birth defects or withdrawal symptoms in newborns. However, for pregnant women with severe depression, the benefits of continuing treatment may outweigh the risks.
• Anticonvulsants: Some anticonvulsant medications, like valproate, are classified as Pregnancy Category D due to the increased risk of birth defects or developmental delays in babies exposed to these medications in utero. However, for pregnant women with epilepsy or other seizure disorders, the risks of uncontrolled seizures may outweigh the potential risks of the medication.
• Methotrexate: Methotrexate is an immunosuppressive medication used to treat certain autoimmune conditions, such as rheumatoid arthritis and psoriasis. As a Category X medication, it is contraindicated during pregnancy due to its potential to cause fetal malformations, growth restriction, and even fetal death. Women who are planning to conceive should discontinue methotrexate therapy and use appropriate contraception for a certain period before attempting pregnancy.

It is important to note that this is not an exhaustive list, and there are other medications that are considered high-risk in pregnancy.

AMA/CPT describes emergent procedures as “typically performed immediately or with minimal delay to allow for patient stabilization.” Procedures frequently performed in the ED that may be considered major surgery or high risk could include but are not limited to:

• Displaced fracture care
• Reduction of an intermediate joint dislocation, e.g., TMJ, acromioclavicular, wrist, elbow or ankle.
• Reduction of a major joint dislocation, e.g., shoulder, hip, or knee.
• Chest tube
• Cardioversion
• Endotracheal tube
• Lumbar Puncture
• Thoracentesis
• Paracentesis
• Intraosseous Catheterization
• Central Venous Catheterization
• Arterial Catheterization
• Cardiopulmonary Resuscitation (CPR)

It includes both. Regardless of whether the decision is to perform the procedure themselves, refer the patient to a surgeon, or admit the patient for surgery, the risk is determined by the decision that the surgery is necessary. This is supported by CMS MAC references at the following links.

• Noridian
• FCSO

Decision regarding hospitalization involves consideration of an escalation of care beyond the ED, such as Observation or Inpatient status. Additionally, the determination of risk also includes decision making when the outcome is to forego further testing, treatment, and/or hospitalization. For example, a decision about hospitalization includes consideration of alternative levels of care.  Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision not to hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment. 

Yes, in the explanation of the risk of complications and/or morbidity or mortality of patient management, CPT specifies that the risk element includes explaining the risks and benefits of possible management options and those considered but not selected after shared decision making with the patient and/or family.

• It is not just the medication; it is the route of administration plus the medication.
• Parenteral, administered by means other than the alimentary tract.
• Controlled Substance – a schedule I, II, III, IV, or V drug or other substance.

This list is not all-inclusive, but ED-relevant parenteral controlled substances may include:

Yes, the need to initiate or forego further testing, treatment, and/or hospitalization/escalation in care can be a factor in the complexity of medical decision making. Examples in which the physician/QHP may elect not to order a test, treatment, or management option include but are not limited to a clinician’s risk/benefit analysis or use of evidence-based risk calculators, or shared decision making.

Yes. Using contrast with a CT can be a valuable tool in diagnosing certain conditions; it can cause adverse reactions in some patients. One of the main risks associated with using contrast is an allergic reaction. An allergic reaction can lead to anaphylaxis, a potentially life-threatening condition in severe cases. In addition, the contrast material can be harmful to the kidneys, especially in patients with pre-existing kidney problems. This can lead to contrast-induced nephropathy, which can cause kidney damage and even kidney failure in some cases.

The additional risk that IV contrast adds to a CT scan is evidenced by the American College of Radiology (ACR) requirement that a physician or PA/NP trained in and capable of managing an acute hypersensitivity reaction provide direct supervision of intravenous contrast administration. The provider of direct supervision must be immediately available to furnish assistance and direction throughout the performance of the procedure. While this does not mean that the supervising provider or radiologist must be present in the room where and when the procedure is performed, there should be at least one person who can recognize adverse events related to contrast media administration in attendance (in the room or in an adjacent control room) to observe the patient during and immediately after the injection and summon medical assistance as needed.

American College of Radiology Contract Media Supervision Requirements

Due to the higher risk associated with a CT with contrast during an ED visit, considering these as a high-risk management decision seems appropriate.

Yes. Moderate sedation in the emergency department may be used to manage patients' pain and anxiety during procedures. However, it is essential to recognize that moderate sedation is not without risks. Risks associated with performing moderate sedation in the emergency department could include respiratory depression, leading to a decrease in oxygen saturation levels which can be life-threatening if not recognized and treated promptly; cardiovascular complications such as hypotension, bradycardia, and tachycardia; allergic reactions ranging from mild to severe and can be life-threatening in some cases.

Due to these potentially life-threatening complications, considering moderate sedation as a high-risk management decision seems appropriate.

Yes, the administration of sedative agents such as benzodiazepines (e.g., lorazepam, diazepam, and midazolam), propofol, ketamine, etomidate, and dexmedetomidine affect the patient's ability to breathe properly, may lead to a drop in blood pressure, anaphylactic reactions, paradoxical reactions and other complications, any of which could be life-threatening.

Yes, using physical restraints for patients in the emergency department can pose several risks.

• Physical injury: Patients may injure themselves while struggling against the restraints, leading to bruises, cuts, or even broken bones.
• Psychological trauma: Being restrained can be a traumatic experience for patients, especially those already vulnerable due to their mental health condition. This trauma can lead to long-lasting psychological effects.
• Respiratory compromise: Restrained patients may experience difficulty breathing, especially if the restraints are too tight or in a position that restricts their breathing.
• Circulatory compromise: Patients restrained for extended periods may experience decreased blood flow to certain body areas, which can lead to serious medical complications.

While physical restraints may be necessary in certain situations, their use is limited to extraordinary situations. The decision to restrain a patient is not taken lightly and should be considered a high-risk patient management option. 

Similarly, placing a patient under “security watch” or equivalent can be poorly perceived by the patient and cause a significant behavioral decompensation which may manifest as increased agitation and aggressive behavior toward the ED staff, themselves or others in the emergency department. 

Yes, administering enoxaparin, heparin, DOACs, or other anticoagulant medication in the ED to treat patients with conditions such as deep vein thrombosis, atrial fibrillation, pulmonary embolism, stroke, or other conditions that require immediate anticoagulation is a high-risk management decision.

These medications can increase the risk of bleeding and other life-threatening side effects. The risk is particularly high in patients with a history of bleeding disorders or those taking other medications, such as aspirin or nonsteroidal anti-inflammatory drugs. These drugs also have significant drug-drug interactions, further adding to their management complexity and risk.

No, even though 99281 does not require that the patient be seen by the physician/QHP, it does require that the patient receives an E/M service. Per CPT Assistant May 2023, “Triage alone is not an E/M service; therefore, it cannot be reported with an E/M code.”

Per AMA/CPT, when reporting 99281, the face-to-face services may be performed by clinical support staff but must be provided under the supervision of a physician/QHP. The RVUs assigned to 99281 are primarily composed of work RVUs to reflect the physician's/QHPs' supervisory role rather than any practice expenses, as the support staff are employed by the hospital.

Based on information from National Government Services, the Medicare Administrative Contractors (MAC) for Jurisdiction 6 (Illinois, Minnesota, Wisconsin) and Jurisdiction K (Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont), E/M code 99281 is applicable for straightforward emergency department care that does not require the active participation of a physician/QHP.  However, the service requires direct supervision of a physician/QHP but does not require personal supervision.

CMS categorizes certain outpatient hospital services based on the level of supervision needed. Services designated as "direct supervision" require the physician to be immediately available to furnish assistance and direction throughout the performance of the service. It does not require that the physician be present at the bedside when the service is performed. On the other hand, services labeled as "personal supervision" mandate that the physician be physically present in the room while the service or procedure is taking place. (Medicare Benefit Policy Manual Chapter 6-20.5.3)

Per NGS, “CPT 99281 may represent straightforward and uncomplicated ED care, not requiring physician or NPP participation. The service requires direct supervision of a physician or NPP but does not require personal supervision at the bedside.”

Triage evaluations may identify patients whose clinical needs do not require physician or NPP participation. Examples of such services would include, but are not limited to: removal of sutures previously placed by a physician or NPP, replacement of a loose or faulty simple surgical dressing, review of previously issued care or medication instructions for which the patient needs further explanation or support."

CPT and CMS policy require supervision when the physician/QHP reports 99281 for services rendered in the emergency department. Although 99281 does not require the physician/QHP to see the patient personally, an E/M service should still have been performed and documented by a member of the clinical care team.

Medicare mandates that the medical record must include a documented date and signature from the billing provider for any professional services covered under Part B. CMS permits the physician/QHP to review and verify (sign and date) notes recorded in a patient's medical record rather than re-documenting the details of the encounter.

No, the CMS Teaching Physician policies have not changed. The CMS Teaching Physician Services policy (Medicare Claims Processing Manual Chapter 12 - 100.1) requires that the teaching physician be physically present during the key or critical portions of any service performed by a resident. The policy defines physically present as located in the same room (or partitioned or curtained area if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

If the service is performed by a student, the teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service.

The American Medical Association (AMA) has revised the CPT guidelines regarding "split or shared visits" for 2024. The definition of a "split or shared visit" now refers to the substantive portion of an Evaluation and Management (E/M) service. The revised definition states that the substantive portion is determined either by more than half of the total time spent by the physician and other qualified healthcare professional (QHP) performing the split visit or by a substantive part of the medical decision making (MDM). These guidelines are intended to assist in determining which healthcare provider, the physician or QHP, may bill for the service.

For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.

The CY 2024 Final Rule indicated that CMS would be adopting the CPT definition of substantive portion for 2024.

The ED physician may review and approve the PA/NP documentation and attest to their performance of the substantive portion of the MDM. For instance, the physician may state:

"I personally made/approved the management plan for this patient and take responsibility for the patient management."

If the assignment of the E/M code relies on Data Category 2 (independent interpretation) and/or Data Category 3 (discussion with an external physician), the ED physician's documentation should include documentation of their independent interpretation and/or reference to any discussions the ED physician had with external physicians or other sources. In these circumstances, the attestation might also include the independent interpretation or discussion of management.

If the ED physician documents the MDM elements they performed during the encounter, e.g., plan of care, interpretations, medications prescribed, discharge instructions, etc., they are not required to additionally document an attestation. The attestation example provided serves as an alternative to the ED physician having to re-document the plan of care or MDM elements that have already been documented by the PA/NP.

See the Shared Services FAQ for additional information.

Yes, observation services will now use the MDM guidelines detailed above, or observation E/M codes can be assigned based on the physician’s total time on the date of the encounter.

However, the Initial Observation Care codes 99218, 99219, and 99220, Subsequent Observation Care codes 99224, 99225, 99226, and Observation Discharge code 99217 have all been deleted for 2023. 

The inpatient E&M codes 99221-99223, and 99231-99239, have been revised to Hospital Inpatient and Observation Care Services.

See the Physician Observation FAQ for more information.

The Office or Other Outpatient E/M codes 99202-99215 have been using the revised E/M guidelines since January 2021. E/M codes 99202-99215 are assigned based on medical decision making or Time. The MDM is determined by the same MDM grid as detailed above. The revised code descriptors indicate the time required for each level of service.

See the Urgent Care E/M FAQ for more information.

They can be found in the Evaluation and Management (E/M) Services Guidelines section of the 2023 CPT Manual. They can be downloaded here.

The only official source for the MDM grid is the 2023 CPT book.