The American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services to the American College of Emergency Physicians (ACEP) for review. 30 years ago, an ER 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 practices.
Documenting a complete history and physical examination will no longer be the deciding factors in code selection in 2023. Instead, the guidelines simply require a medically appropriate history and physical exam. That leaves medical decision-making as the sole factor for code selection going forward. Time is not a descriptive component for 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.
These codes have also been revised to delete references to the level of history and examination and include the level of medical decision-making. Time is not a descriptive component for these codes as the services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period. Medical decision-making is the only available method for selecting these codes.
Understanding how to properly document and code these high-volume services is important, as even small mistakes in E/M coding can result in major compliance and payment issues. The updated E/M guidelines for 2023 aim to simplify and streamline coding and documenting for E/M services and are being welcomed by physicians and providers of medical billing and coding services.
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Sam Patterson – AVP