2023 AMA CPT Documentation Guideline Changes for ED E/M Codes 99281-99285

David McKenzie, CAE

On July 1st, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once in a generation restructuring of the guidelines for choosing a level of ED E/M visit impacting roughly 85% of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service 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. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

Table: 2023 ED E/M Definitions

• 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 critical care codes (99291 and 99292) were not impacted by the 2023 documentation guideline changes.

Medical decision making (MDM) in 2023 is too complicated to fully address in this forum, but it will still be based on the modified historic three MDM components with the eventual visit level assigned scored using the highest two of three components. These are:

Number and complexity of problems addressed – There is no longer a major distinction made for additional workup planned, and no longer points for a new problem to the examiner. 2023 requirements will be less numeric and more qualitative including terms such as acute uncomplicated injury, acute illness with systemic symptoms, and chronic illness with severe exacerbation.

Amount and or complexity of data to be reviewed and analyzed – This component has the most changes in clarifications, including scoring for ordering or reviewing each unique test. New changes include points awarded for review of prior external notes and use of an independent historian as well as for testing you considered but did not order (such as a Pediatric Head CT for a minor blunt injury).

Risk of complications and or morbidity or mortality of patient management – This is still based on the previous “table of risk” with the highest element of risk prevailing for the level assigned. Changes for 2023 include, at the moderate risk level, diagnosis and treatment significantly limited by social determinants of health and prescription drug management considered. At the high-risk level, there is now credit given for decision regarding hospitalization or escalation of care.

Beyond the new MDM table, other favorable 2023 language includes:

• “The final diagnosis for a condition does not in itself determine the complexity or risk as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.” This helps reinforce the concept of the prudent layperson standard.
• “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”
• “Ordering a test may include those considered but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition. The
  discussion of the lack of benefit may be required. Alternatively, a test may be normally performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented.”

CMS is on record through the rulemaking process that it will adopt the MDM guidelines as revised by CPT, if not all the prefatory language and interpretive guidance framework issued by the AMA CPT, because it believes it would accomplish greater burden reduction.

The ACEP Coding and Nomenclature Advisory Committee (CNAC) has developed a comprehensive FAQ set to introduce the new CPT guidelines for ED practice. It will be updated as we learn more, but the current version can be found at this link to the ACEP website.

In fact, in mid-March 2023 CPT released an errata statement with changes effective retroactively to January 1, 2023. Two changes relevant to ED E/M selection include added language to the definitions of an independent historian and an appropriate source from the MDM grid middle column “Amount and complexity of data to be reviewed and analyzed as shown below:

Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.

Appropriate source: For the purpose of the discussion of management data element (see Table 1, Levels of Medical Decision Making), an appropriate source includes 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). It does not include discussion with family or informal caregivers. For the purpose of documents reviewed, documents from an appropriate source may be counted.

Mr. McKenzie is the ACEP Director of Reimbursement and staffs the ACEP CPT and RUC Teams and the FEC Section. He can be reached here.