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2023 E/M
Overview

The E/M Guidelines for ED practices are changing  January 1, 2023 and may have a significant impact on practice revenue if clinicians do not adapt their documentation to meet the new guidelines.

The following are the key changes with the 2023 E/M Guidelines:

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  • Medical Decision Making (MDM) is the sole determinant of the E/M level of service.  It is essential clinicians fully document your medical decision making processes in assessing and treating a patient.

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  • History and/or Physical Examination (H&P) is no longer a factor in determining the E/M level of service.

    • H&P must still be documented to support the problem component of MDM

    • Extent of the H&P is determined by the treating physician / APP and should be medically appropriate to the individual patient

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  • 3 Components determine the MDM Scoring (highest of 2 of 3)

    • Problem​ - Number and complexity of problems addressed at the encounter

    • Data - Amount and complexity of data reviewed and analyzed

    • Risk - Complications and/or morbidity or mortality of patient management

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It will be more critical than ever to document what you are thinking in addition to what you are doing with these 2023 changes.

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  • Document your considerations of treatment even they are not performed.

  • Problem - Differential diagnoses considered

  • Data - Diagnostic tests appropriately considered

  • Risk - Hospitalization considered; medication/treatment considered​

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Why are the E/M Guidelines changing after all these years?

According to the American Medical Association (AMA), the 2023 E/M Guidelines are intended for face-to-face interaction with the patient and to simplify coding and documentation requirements for health care providers and improve patient health under the following five principles:

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  • Align CPT and CMS guidelines whenever possible

  • Decrease administrative burden of documentation and coding

  • Decrease the need for audits

  • Decrease documentation in the medical record that is not needed for patient care

  • Ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties

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Below are the CPT Codes for the E/M Services provided in the ED.
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More Resources

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