The table above is the rubric for billing starting January 1st. This is the sole guide to determining E/M level for billing purposes. The level of MDM is defined as either Straightforward, Low, Moderate, or High risk. These correspond to CPT codes 99282-99285 respectively. 99281 is no longer applicable for any patient seen by a physician. The three columns are the complexity of problems addressed(also referred to as CoPA), the data column, and the risk column. In order to get to a certain level you must satisfy the requirements for two out of the three columns for that level. Ie, must have two columns in the moderate level to bill moderate(99284) risk/MDM. Let’s go through some points from each column.

COPA – This is the complexity of the problems addressed. It is a combination of the patient’s history that is relevant to the presenting complaint as well as the differential which shows potential severity. For example, diabetes increases the complexity of a foot wound or being anti coagulated increases risk of minor head trauma…history of fibromyalgia doesn’t increase the complexity of dental pain. 

• Just having problems listed in the history does not qualify them for COPA. It is your job to document that their history of X is relevant to presentation. 
• Many of the terms used to qualify COPA are vague. Thankfully, part of the new changes are that the determination of appropriate ROS, Exam, and probably severity of illness lies with the provider and is not dictated by the final diagnosis or  how many bullets were clicked, it is based on what you as the physician decides.
• Statements like “this is a severe exacerbation of X” or “this presentation poses a threat to life or bodily function” are all that are needed to get to a high COPA. As always it needs to be true if you’re going to put it in the note. 

Data – This is the complexity of data ordered, reviewed, and analyzed.  There are three basic categories to be considered. Of note the categories do changes between low and moderate but you can figure that out with the rest of this description and let’s be real how many of our patients meet a level 2 anyway? So the main categories are 1.) Tests, documents, or independent historian(s) 2.) Idependent interpretation of tests and 3.) Discussion of management or test interpretation.

Category 1 is obviously related to the tests ordered and data collected/reviewed. 

• A test is determined to be unique if it has its own CPT code. For example a CBC and a BMP are considered two separate CPT codes.
• Reviewing the unique test means you commented on the results.
• This is new, review of prior external note(s) from each unique source no longer includes prior ED notes. It has to be records from a different facility or specialty.
• Assessment requiring independent historian is as it sounds. This now includes parents which was not the case previously. This applies not only to when the patient cannot give information, but also to when other historians are needed to make appropriate decisions requiring the patient’s care. 

Category 2 is regarding the independent interpretation of tests. These cannot be billed by you. You can read an EKG but if you want to use it for MDM it cannot be billed. What this does allow us to do is get credit for bedside interpretations of time sensitive imaging such as CXR in trauma to determine if chest tube is needed prior to CT. It is going to get formally read but we will get credit for the time-sensitive gross read.

• This does not require us to give a formal interpretation. Only a statement such as “reviewed CXR at bedside, no gross abnormality, pending formal read” as far as I can tell. 
• This doesn’t give credit for commenting on labs as those do not require a formal interpretation to bill the CPT code. They are simply a test with displayed results. Also you got credit for that in category 1.

Category 3 is discussion of management or test interpretation. 

• This is basically any consult
• This also includes simple things like speaking to the radiologist about a read. Probably even getting a call from them about a negative CT brain for stroke protocol. 

Risk – This is the part where obviously the risk of management is determined. There is A LOT of ambiguity in this one because most of what CMS provided were only examples without any distinct criteria. Basically if there is any risk you are going to be at a moderate level. This is going to be where knowing the correct phrases is very helpful. A big portion of this column is going to come down to shared decision making. Keep in mind the word “decision” does not imply that a certain action was taken. Even if the patient was not admitted, the fact you consider it counts. Some thoughts below:

• Prescription drug management is, as far as we know, any time you write an Rx it counts
• Social determinants of health(SoDH) consists of limitations on the ability for the patient to receive adequate care which could change your management. These have note been explicitly stated. There are actually many Z codes in ICD-10 which would probably qualify for SoDH. The common sense thing is that if there is something in the patient’s life that is going to limit their ability to get care after the ER or if you had to adjust your management because of this then you need to document it. A few examples are financial limitations, homelessness, substance abuse issues, unemployed or transportation limitations
• Drug therapy requiring monitoring would obviously be your high-risk meds such as opiates, benzos, etc… It would also include paralytics and cardio active meds but you’re going to bill critical care for that anyway(you should be if not) so the E/M level doesn’t matter
• Decisions regarding emergent major surgery or de-escelation of care/DNR status is pretty obvious but it does require documentation of the shared decision making.
• Decision regarding hospitalization is a big one for us. As stated above, if you are truly considering admission, even if the patient ends up discharged that still counts. The big part is you just have to document it

What this comes down to is you are going to need to spend more time dictating the thoughts that go through your head. If you already do this and represent your though process through MDM and rational then great! You’re only changes are going to be knowing a few key phrases to say. We have suggestions for these phrases under the MDM section here. If you have been just relying on the click boxes and skeleton notes that simply get you to a certain E/M level as has been the way of the past, you are going to need to get to know that dictation mic a lot better going forward!

Also, keep in mind these changes DO NOT affect Critical Care(CPT 99291/99292) at all and if you bill CC time then your E/M level is still irrelevant.