About This Website

This is a free website and interactive coding tool to help ER physicians understand the new 2023 Emergency Department Evaluation and Management Guidelines. It can suggest a level of service (LOS) E/M code (e.g. 99282, 99283, etc) given the complexity of problems addressed, data reviewed, and risk of complications of patient management in the Emergency Department.

It features an instant 'copy-to-clipboard' feature so you can paste a suggested LOS into your chart.

Resources / Links

Official AMA 2023 CPT (pdf)
ACEP 2023 ED Guidelines FAQ
ACEP 2023 MDM Grid (pdf)

Any questions, comments, or feature requests please email Steve Garcia, MD at emcoding2023@yahoo.com.

Disclaimer: This website is my interpretation of the guidelines put forth by the AMA and ACEP. My interpretation may differ from others. This tool has not been sanctioned or endorsed by any official medical organization. If you have questions I recommend you talk to your billing / coding team.

Current Version: (released ).

Should be supported on all modern browsers (e.g. Edge, Chrome, Firefox, Safari). It may not function properly on Internet Explorer. This website does not use cookies nor does it store information.

Level of MDM

The appropriate level of Evaluation and Management (E/M) services in the Emergency Department still uses CPT codes 99281 - 99285, however 99281 is no longer used in the ED. There should be no charts with a code of 99281.

For 2023, the ED E/M CPT codes are based exclusively on Medical Decision Making (MDM). Prior to 2023, the E/M CPT codes were based on different criteria such as number of elements in the HPI, number of physical exam findings documented, number of review of systems documented, and so on.

How is the Medical Decision Making determined?

A grid is now used to "score" the three subcomponents of the MDM. These subcomponents are

The number and Complexity Of Problem(s) Addressed during the encouter (COPA)
The amount and/or complexity of DATA reviewed and analyzed (DATA)
The RISK of complications, morbidity, and/or mortality of patient management decisions made, associated with the patient's problems, diagnostic procedures, and treatments (RISK).

The level of MDM is based on 2 of the 3 subcomponents above being met. It is very important to understand this. In order to arrive at an E/M score (e.g. 99282, etc), first one must score each subcomponent above COPA, DATA, and RISK. These scores can either be "minimal", "low", "moderate", or "high". See the table below:

E/M	MDM	COPA	DATA	RISK
99281	N/A	N/A	N/A	N/A
99282	Straight Forward	Minimal	Minimal (or none)	Minimal
99283	Low	Low	Limited	Low
99284	Moderate	Moderate	Moderate	Moderate
99285	High	High	Extensive	High

To qualify for a particular level of MDM, two of the three elements (subcomponents) for that level of MDM must be met or exceeded. (page 7)

Examples: Rollover the list below to visualize examples.

The way to calculate the MDM score is 1) score all three elements with "minimal", "low/limited", "moderate", or "high/extensive". Then of the three scores, drop the lowest score. Then of the remaining two scores, take the minimum score. That is the MDM level.

If COPA = minimal, DATA = minimal, RISK = minimal, first drop the lowest score (in this case all three are "minimum". So it doesn't matter whether COPA, DATA, or RISK are dropped. So let's drop COPA.) Of the remaining DATA and RISK scores, take the minimum value. In this case since they are the same, your MDM will be "straightforward" or 99282.

IF COPA = low, DATA = extensive, RISK = moderate, first drop the lowest score. This would be COPA. Then of the remaining two scores DATA and RISK, take the minimum score. It is moderate. So the MDM will be "moderate" or 99284.

If COPA = high, DATA = limited, RISK = minimal. First drop RISK. Of the remaining two scores COPA and RISK, the minimum score is "limited". So the MDM will be "low" or 99283.

If COPA = minimal, DATA = extensive, RISK = minimal, first drop COPA (or RISK). Of the remaining two scores DATA and RISK, the minimum score is minimal. So the MDM will be "straightforward" or 99282

If COPA = moderate, DATA = extensive, RISK = high, drop COPA. Of the remaining two scores DATA and RISK, the minimum score is extensive or high. So the MDM will be "high" or 99285

Explanation of the MDM

This is an optional field. You can use the script generator without ever entering explanations.

There might be times, however, that you want to explain why you chose an item in COPA, DATA, or RISK. Sometimes it might be obvious from your chart, and other times it might not. Anything entered into these text boxes will be appended to the script under the appropriate category.

Examples:

In COPA, you might want to explain why the chest pain workup was of highest complexity. For instance "pt had chest pain and tachycardia and was low risk for PE per Wells. The DDimer was negative. Therefore did not order a CT." This kind of complexity illustrates the significance of the complexity of problems addressed.

In DATA, you can indicate which prior notes and labs reviewed, such as "reviewed the discharge summary on 4/9/2022" or "reviewed BMP, CBC, and UA from 8/6/2020".

In RISK, one might want to indicate the social determinants of health if not listed in the chart. For instance "homeless with substance abuse addiction."

Complexity of Problems Addressed - Minimal - 1 self-limited or minor problem

Summary

It is highly improbable that patients who present to the ED fit into this category. This category should almost never be used. See examples below.

Explanation

AMA Definition:

The AMA defines a self-limited or minor problem as "A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status."

ACEP Interpretation:

"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 (emphasis mine). 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."

Examples:

Packing removal
Dressing change
Needing COVID test (without symptoms) to get cleared to go back to work
Some requests for work notes
Suture Removal
Very minor abrasions
Bug bite

Complexity of Problems Addressed - Low - "Acute, Uncomplicated Illnes or Injury"

Summary

Acute, uncomplicated, and localized complaints to the ER will most often fall under this level of complexity. Remember that these are injuries or illnesses that almost never require testing, imaging, or prescription medications.

Explanation

AMA Definition:

The AMA defines this as "a recent or new short-term problem with 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."

ACEP Interpretation:

ACEP does go into detail about this category. These include:

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.

"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.

Examples:

Simple lacerations or abrasions (not requiring repair, imaging nor antibiotics)
Isolated URI symptoms
Self-limiting rashes (e.g. molluscum contagiosum)
Mild joint and muscle aches
Mild muscle strains

Complexity of Problems Addressed - Low - "Stable, Acute or Chronic Illnesses"

Summary

These two choices should almost never be used in the ED. Remember that the CPT definition of "stable" is not the same definition ER doctors use. Stable has nothing to do with hemodynamics. Stable means the illness is at it's baseline or treatment goal.

Occasionally people do come back to the ED for rechecks of stable, acute illnesses. They may not have outpatient followup. Perhaps their cellulitis has improved and they want reassurance that they are healing well.

Explanation

AMA Definition:

The AMA defines stable, acute illness as "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."

The AMA defines stable, chronic illnesses as "A problem with an expected duration of at least one year or until the death of the patient. The chronic illness is 'stable' if they are at their treatment goal."

ACEP Interpretation:

ACEP briefly comments about this category and suggests that given the CPT definition of "stable", it is doubtful that patients presenting to the department fit into these categories.

Examples:

Stable, acute illnesses are also ones that ought be addressed as an outpatient:

Diagnosed with acute bronchitis 1 week ago and is improving
Diagnosed with anemia last month and on iron supplementation, anemia is improving, but not yet at target
Diagnosed cellulitis and on antibiotics, came for a re-check
Diagnosed with AKI due to gastroenteritis and told to re-check their kidney function, and are now asymptomatic

as you can imagine, the list is endless.

Stable, chronic illnesses are that, chronic problems without exacerbations:

Hypertension
Chronic low back pain
Anemia
Asthma / COPD
CKD
Hypothyroidism
NASH
Movement disorders
Rheumatoid arthritis

and as you can imagine, the list is also endless. It includes illnesses that are not associated with exacerbations.

Complexity of Problems Addressed - Low - "1 acute, uncomplicated illness or injury requiring hospitalization"

Summary

It is not recommended that this bullet point be used in the ED.

Explanation

AMA Definition:

The AMA defines this as "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."

ACEP Interpretation:

ACEP very clearly writes "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."

Perhaps this is for direct admissions who require induction treatment for medical illnesses that cannot be accomplished at home?

Complexity of Problems Addressed - Moderate - "1 Acute Illness, Injury, or New Problem"

Summary

These three classifications should be frequently used in the ED:

1 acute, complicated injury

1 acute illness with systemic symptoms

1 undiagnosed new problem with uncertain diagnosis

Patients often present with an acute injury or illness that is at least moderately complex.

Be careful that fever does not always mean systemic symptoms.

Explanation

AMA Definition:

The AMA does not write much about an acute, complicated injury. It is defined as "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."

ACEP Interpretation:

ACEP is more clear that a complicated injury requires an evaluation of organ systems or body areas beyond just the injury site.

The mechanism of injury can be an indication of a complicated injury.

Accidents that necessitate diagnostic imaging to rule out significant clinical conditions such as fracture, dislocation, and foreign bodies are indicative of a complicated injury

Examples (of an acute, complicated injury)

Ankle injury requiring an xray and/or assessment of neurovascular function
Fight with evidence of trauma to multple body areas
Ground level fall with evidence of trauma to multiple body areas
Foreign body (e.g. a nail) in an extremity
Hand slammed in a door
Animal bite to an extremity
Partial-thickness scald burn
Laceration requiring assessment of neurovascular function
Laceration requiring suture repair

Complexity of Problems Addressed - Moderate - "1 Acute Illness, Injury, or New Problem"

Summary

These three classifications should be frequently used in the ED:

1 acute, complicated injury

1 acute illness with systemic symptoms

1 undiagnosed new problem with uncertain diagnosis

Patients often present with an acute injury or illness that is at least moderately complex.

Be careful that fever does not always imply moderate complexity. See below.

Explanation

AMA Definition:

The AMA writes "An illness that causes systemic symptoms and has a high risk of morbidity without treament. For systemic general symptoms such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see self-limited or minor problem or acute, uncomplicated illness or injury." This is key. The AMA is proposing that not every single systemic symptom implies moderate complexity. "Systemic symptoms" appears to be open to interpretation.

ACEP Interpretation:

ACEP spends some time discussing systemic symptoms. First, "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.

Fever is generally considered to likely represent a systemic response to an illness. However "CPT states that fever associated with a minor illness is more typical of an uncomplicated illness." Ultimately the illness causing the fever must be evaluated for it's complexity and risk of morbidity. A fever from a viral URI is generally considered uncomplicated. A fever from the kidneys, skin, lung, or other organs can be viewed as at least moderately complex. For instance if one is prescribing antibiotics, or using diagnostic testing, for the illness causing a fever, "that may represent a broader complexity of problem being addressed or treated."

Examples (of an acute illness with systemic symptoms):

The following is not an all-inclusive list:

Abdominal Pain
Back Pain
Chest Pain
Vomiting, Diarrhea
Dizziness
Headache, Neck Pain
Some Pyschiatric Complaints
Shortness of Breath
Systemic Rash
Weakness
Syncope

warning Key Point:

"At the moderate level, diagnostic evaluations would likely involve simple testing, such as plain x-rays or basic lab tests."

Complexity of Problems Addressed - Moderate - "1 Acute Illness, Injury, or New Problem"

Summary

These three classifications should be frequently used in the ED:

1 acute, complicated injury

1 acute illness with systemic symptoms

1 undiagnosed new problem with uncertain diagnosis

Patients often present with an acute injury or illness that is at least moderately complex.

Be careful that fever does not always imply moderate complexity. See below.

Explanation

AMA Definition:

The AMA simply writes "A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment" The AMA offers little additional guidance on this topic.

ACEP Interpretation:

ACEP also uses few words clarifying this topic. ACEP does give an example of "a patient with no history of abdominal pain who presents with acute abdominal pain."

There are other web resources that expand on this topic. Think of patients who present with signs and symptoms, and after an appropriate medical screening exam in the ED no conclusive diagnosis can be made and additional work-up is needed.

Examples (of a new problem with uncertain prognosis):

A breast lump. A medical screening examination (MSE) in the ED with labs and imaging might not reveal an emergency medical condition (EMC), but the prognosis is unclear. The patient requires further outpatient evaluation. Even if the evaluation ultimately results in a benign diagnosis, the differential diagnosis is broad and includes breast cancer.

PVCs on an EKG. An appropriate MSE might not reveal an EMC, but further outpatient evaluation is usually warranted to assess for a cardiomyopathy.

Leg swelling. An appropriate MSE might rule out a DVT, cellulitis, heart failure, or other EMC, but further outpatient evaluation is usually warranted to assess for lymphedema or medication side-effect.

Hyperglycemia, new onset

Hypertension, new onset

Thrombocytopenia

Epigastric pain and suspected gastric ulcer from H. Pylori.

Palpitations. The patient may not have an EMC, but warrants outpatient evaluation with an event monitor.

Microcytic anemia

warning Key Point:

If you use this selection, make sure you document a differential diagnosis of at least moderate complexity and risk that needs to be further evaluated on an outpatient basis.

Complexity of Problems Addressed - Moderate - "1+ Chronic Illness with Exacerbation..."

Summary

This should be used frequently. We see patients every shift who have an exacerbation of a chronic health problem.

Explanation

AMA Definition:

"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."

ACEP Interpretation:

This category is self-explanatory. ACEP doesn't write about it in detail. ACEP does clarify that the "text should be interpreted as chronic illnesses with exacerbation, OR progression, OR side effects of treatment."

Complexity of Problems Addressed - High

Summary

Both of these categories should be used often. The core competency of emergency medicine is resuscitating and stabilizing critically ill patients.

Explanation

AMA Definition:

The key words authored by AMA include "significant risk of morbidity and may require escalation in level of care" and "...poses a threat to life or bodily function in the near term without treatment."

ACEP Interpretation:

I believe ACEP makes it crystal clear that the ultimate diagnosis does not determine the complexity of the presenting complaint. For example:

"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."

"It is not necessary that these conditions be listed as the final diagnosis."

Lastly, ACEP unequivocally writes and italicizes following text for additional emphasis.

"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."

Examples:

The following is not an all-inclusive list:

Active labor
Ectopic pregnancy
Acute intra-abdominal infection or inflammatory process
Behavioral health decompensation
Cardiac arrhythmia
Cardiac ischemia
Croup or asthma requiring significant treatment
CVA, acute neurological change
DKA or other significant complications of diabetes
Endocrine emergencies
Epiglottitis
Exacerbation of CHF
Exacerbation of COPD
Gastrointestinal / bowel obstruction
Hypertensive crisis
Intracranial hemorrhage
Intra-thoracic or inra-abdominal injury due to blunt trauma
Kidney stone with potential complications
Missed/incomplete abortion
Ocular emergencies
Ovarian torsion
Pulmonary embolism
Seizure
Sepsis
Sickle Cell Crisis
Significant blood loss / hemorrhage
Significant complications of pregnancy
Significant fractures or dislocations
Significant metabolic disturbance
Significant penetrating trauma
Significant vascular disruption, aneurysm, or injury
Solid organ injury
Testicular torsion
Toxic ingestion

warning Key Point:

Presenting complaints can be highly complex, pose significant risk of morbidity or threat to life, and require a substantial evaluation. The final diagnosis does not determine the complexity of the MDM. Document well!

Data Reviewed and Analyzed - Tests Ordered

Summary

A test is ultimately defined by the CPT code set. e.g. "CBC", "Troponin", "2V Chest Xray", "US Renal"

Explanation

AMA Definition:

The AMA broadly (and in my view somewhat obtusely) defines "Test", test "Analysis", and test "Uniqueness". Because the 2021 and 2023 CPT E/M guidelines apply to broad categories of health care including ambulatory, hospital, surgical, emergency department, consultation, nursing home, and urgent care, the guidelines appear to be generic and allow for specific interpretation within each category.

ACEP Interpretation:

ACEP does an better job explaining "tests ordered" as it applies to the ED.

Examples:

Each test is unique. This is defined by the CPT code set. If you order a CBC, BMP, Troponin, EKG, and chest x-ray, that counts as 5 tests.

It is assumed when you order a laboratory test in the ED, you will also review it. You cannot score 2 "points" for ordering a CBC and analyzing/reviewing it.

When the same test is ordered multiple times (e.g. serial blood glucose, repeat EKG), it counts as one unique test.

Vital signs and pulse oximetry are not tests. They are vitals signs.

Data Reviewed and Analyzed - Tests Considered

Summary

A test considered (but not ordered) is considered equivalent to a test ordered as outlined by the AMA CPT and ACEP.

Explanation

AMA Definition:

The AMA indicates that "ordering a test may include those considered but not selected after shared decision making. These considerations must be documented."

ACEP Interpretation:

ACEP adopts this CPT position statement and also provides some examples. The examples include but are not limited to use of evidence-based risk calculators.

Examples:

Canadian CT Head Injury Rule
NEXUS and Canadian C-Spine Rules
Ottawa Ankle and Knee Rule
PECARN for Pediatric Head Injury
PERC Rule for Pulmonary Embolism
Wells Criteria for DVT
Wells Criteria for PE

Data Reviewed and Analyzed - Tests Reviewed

Summary

You are credited for reviewing test results, just not the laboratory tests you ordered.

Explanation

AMA Definition:

ACEP Interpretation:

ACEP does provide some clarification on tests reviewed, but it is still confusing. As written above, you cannot review laboratory tests that you order. You can review prior laboratory tests though. You can review imaging and EKGs you order that have been officially read by another physician. You can also review tests (laboratory and imaging) brought to you by the patient, for instance if performed at another facility.

Examples:

Your patient has a creatinine is 3.4. You review a creatinine from 6 months ago and it was 1.3. That counts as one reviewed test (the one from 6 months ago).

A patient is sent into the ED for an outpatient potassium level of 6.3. Your review of that BMP counts as one reviewed test.

A nursing home patient is sent into the ED for an evaluation of cough and weakness. The nursing home sends health records, a chest xray report, BMP and CBC performed 2 days ago. This counts as three reviewed tests (and one reviewed external note.)

EMS brings a patient for chest pain and provides you a 12-lead EKG they performed in the ambulance. That review counts as one reviewed test. It might even count as an independent interpretation of an EKG since you will not be billing for that interpretation (need clarification).

You are treating a patient with shortness of breath and review a recent echocardiogram.

You are treating a patient with black stool on anticoagulation and you reviewed the results a colonoscopy test performed earlier in the year.

You order and review a CT scan in the ED. You compare it to CT scan performed and read 2 months ago. This counts as a test reviewed (and an independent interpretation of the current CT.)

Data Reviewed and Analyzed - Prior External Notes

Summary

You are credited for reviewing prior, external notes from physicians, facilities, or notes from other health care organizations. This does not include reviewing medical records from providers in your department from the same hospital.

Explanation

AMA Definition:

The AMA defines "External" and "External physician" in the context of prior notes in a straight forward manner:

External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization.

An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty.

ACEP Interpretation:

ACEP provides clarity in their interpretation of the guidelines. They write "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."

The caveat is that "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."

Examples:

Hospital admission notes, daily SOAP notes, and discharge summary

Outpatient clinic note

Inpatient or outpatient consultation note

Nursing home records

Medical records from the patient's care provider

EMS call documentation

ED charts from a different hospital system

Medical records brought from jail or prison

Note: Reviewing a prior note should be germane to the patient complaint. If a patient complains of traumatic toe pain and you are reviewing their prior pulmonary consultation note, you need to explain why that was necessary to render medical care for that visit.

Data Reviewed and Analyzed - Independent Historian

Summary

This is straightforward. You are credited for obtaining history from an independent historian when the patient is unable to provide a complete or reliable history.

Explanation

AMA Definition:

There is little ambiguity with the definition of an independent historian.

Any individual (e.g. parent, guardian, surrogate, spouse, witness)

The individual provides history in addition to the patient who is unable to provide complete or reliable history.

This does not include translation services.

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 (e.g. a phone call).

ACEP Interpretation:

ACEP has an FAQ dedicated to this topic. It is self explanatory and please see question #16. There should be little confusion about this topic.

It is important to remember that if the patient is able to give a complete and reliable history, the presence of additional historian(s) will not count towards data collected. For instance, if a 14 year old patient presents with knee pain while playing sports, for the purposes of that complaint the teenager could provide a complete and reliable history.

Data Reviewed and Analyzed - Independent Interpretation of Tests

Summary

You can increase the level of MDM if you independently interpret a test that you will not bill in the future.

Explanation

AMA Definition:

The AMA discussess qualifications to receive credit for independent interpretation of tests.

The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. (This is why we cannot independently interpret blood tests, because it is not customary to create a report. They are just numbers.)

A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

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.

The last bullet point will probably be a source of confusion among ER doctors.

ACEP Interpretation:

ACEP has a few FAQs dedicated to independent interpretation. They state "examples include X-ray, EKG, ultrasound, CT scan, and rhythm strip interpretations." . In many emergency departments, ED physicians separately bill for EKG interpretation (CPT 93010). One cannot independently interpret an EKG and also bill for the official interpretation at the same time.

What can be confusing is both the AMA and ACEP write "...independent interpretation does not apply when the physician or other qualified health care professional reports the E/M service...". Is the radiologist the "other qualified health care professional?" Does this imply that if a radiologist is going to officially read and bill for the interpretation, it cannot be independently interpreted by the ER physician? (need clarification).

Data Reviewed and Analyzed - Independent Interpretation of Tests

Summary

You receive credit if you consult with another physician or appropriate source.

Explanation

This is a straightforward category and both the AMA and ACEP outline the criteria. There are caveats as outlined below:

Discussion requires an interactive exchange (you cannot leave a voice message).

The exchange must be direct - cannot be through nonclinical intermediaries (e.g. office assistant sending messages to the consultant.)

Sending a chart note does not qualify.

It may be asynchronous, it does not have to be in person (e.g. an interactive text or email conversation qualifies)

Consultation with someone in your same group (a fellow ER doctor in your group) does not qualify

Consultation may be performed with select non-medical staff involved in the management of the patient: e.g. nursing facility, home health care agency, lawyer, parole officer, case manager, teacher

Consultation with family or informal caregivers does not qualify.

Risk of Complications and/or Morbidity and Mortality

Summary

The EM physician can apply common language usage meanings, in accordance with their training, for minimal, low, medium or high risk.

Explanation

AMA Definition:

The AMA very briefly and broadly touches on "Risk" and "Morbidity". The key sentence, in my opinion, is "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." . It is clear that the AMA wants specialties to define and own the assessment and level of risk. The AMA continues to write "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions". .

If an EM physician writes that the patient is at medium or high risk for morbidity or mortality, the physician ought not define medium or high.

ACEP Interpretation:

ACEP does not offer a more tailored set of high level guidelines about how to measure risk of complications and/or morbidity and mortality. This is left up to the EM Physician. In fact, the ACEP Risk column is the same as the generic AMA Risk column for ambulatory medicine. ACEP does offer definitions for some specific scenarios within Risk. See the appropriate help sections.

warning Key Point:

ACEP does not provide uniform definitions for minimal, low, moderate, or high risk. ACEP does provide some specific examples to help guide the EM physician.

Risk of Complications and/or Morbidity and Mortality - Moderate - Drug Administration and Management

Summary

Administering any prescription drug in the ED, or writing, modifying, discontinuing, or maintaining the patient's current drug prescriptions qualifies for this selection.

Explanation

AMA Definition:

The AMA does not specifically define "prescription drug management" despite stating it as an example under moderate risk.

ACEP Interpretation:

ACEP does define prescription drug management. It is similar to other specialties definitions.

Examples:

any administration of prescription strength medication while the patient is in the ED

a prescription written to be filled at the pharmacy

discontinuation or modifications to the patient's existing medication dosages

after consideration of the current medications, the decision to maintain the current medication regimen

NOTE: Simply listing current medication is not considered prescription drug management.

Risk of Complications and/or Morbidity and Mortality - Moderate/High - Minor and Major Surgery

Summary

Surgery - Minor or Major is based on the common meaning of such terms in Emergency Medicine.

Explanation

AMA Definition:

The AMA very broadly defines "minor and major" surgery. The defintion appears to be specialty specific.

ACEP Interpretation:

ACEP doesn't further define minor and major surgery, but does provide some examples. I added others:

Examples of Minor Surgery:

Incision and drainage
Foreign body removal (e.g. from wound, cornea, nose, ear, etc.)
Wound repair with sutures
Wound debridment

Examples of Major Surgery:

Chest tube
Reduction of bone fracture
Reduction of intermediate dislocated joint (e.g. wrist, elbow)
Cardioversion
Intubation
Thoracentesis
Paracentesis
Procedural sedation to perform the procedure

It is not clear from ACEPs guidance how to classify several commonly performed procedures in the ER as even being a procedure, minor, or major. These include:

Closing wounds with glue or steristrips
Cerumen disimpaction
Hernia reduction
Foley placement
Gastric tube placement
Lateral canthotomy with cantholysis
Central line placement

Risk of Complications and/or Morbidity and Mortality - Moderate - Social Determinants of Health

Summary

Nonmedical factors that increase the risk of morbidity and mortality.

Explanation

AMA Definition:

The AMA simply writes "Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity."

ACEP Interpretation:

ACEP provides a few examples. Additionally in a separate AMA publication there are examples of social determinants of health (SDOH). It appears Emergency Physicians can reference ICD-10 Z codes for this topic. Note it is not necessary to include the z code as a diagnosis.

ICD-10 Z-Codes:

Z55 - Problems related to education and literacy
Z56 - Problems related to employment and unemployment
Z57 - Occupational exposure to risk factors
Z58 - Problems related to physical environment
Z59 - Problems related to housing and economic circumstances
Z60 - Problems related to social environment
Z62 - Problems related to upbringing
Z63 - Other problems related to primary support group, including family circumstances
Z64 - Problems related to certain psychosocial circumstances
Z65 - Problems related to other psychosocial circumstances

Common Examples in the ED:

Homelessness
Low-level literacy and illiteracy
Unemployment
Military deployment status
Occupational exposures to toxins, smoke, etc.
Lack of adequate food
Transportation insecurities
Financial insecurities
Domestic abuse or neglect
Problems related to unwanted pregnancy

warning Key Point:

The ICD-10 code is NOT required to be coded on the claim.

Also remember that the existence of an SDOH itself is not the determining factor. Diagnosis and treatment must be significantly limited by social determinants of health.

Risk of Complications and/or Morbidity and Mortality - High - Parenteral controlled substances

Summary

Administering parenteral controlled substances can be indicative of a high risk presenting complaint.

Explanation

AMA Definition:

The AMA lists this category but offers no detailed explanation.

ACEP Interpretation:

ACEP clarifies that the medication must be a controlled substance (a schedule I, II, III, IV, or V drug) and must be administered by means other than the alimentary tract. It provides a list that is not all-inclusive:

Examples:

Buprenorphine (Suboxone)	Lorazepam (Ativan)	Morphine	Stadol
Diazepam (Valium)	Meperidine (Demerol)	Naloxone (Narcan)	Sufentanil
Fentanyl	Methadone	Nubain	Talwin (pentazocine)
Hydromorphone (Dilaudid)	Methohexital	Pentobarbital	Thiopental
Ketamine	Midazolam (Versed)	Phenobarbital

Risk of Complications and/or Morbidity and Mortality - High - Drug Therapy Requiring Intensive Monitoring for Toxicity

Summary

There are medications that have the potential to cause serious morbidity or death and must be monitored for adverse effects.

Explanation

AMA Definition:

The AMA has an section and further clarifies this topic:

The monitoring may be performed with a laboratory test, a physiologic test, or imaging
Monitoring by history or examination does not qualify.

ACEP Interpretation:

ACEP gives further clarification for what's needed to satisfy this category. They provide a not all-inclusive list:

Examples:

Administering blood products
Bicarbonate IV
D50 / Glucagon
Epinephrine (any route)
Haldol IV (and IM [my emphasis])
Insulin IV Drip
Magnesium IV
Potassium IV
Calcium IV
Thrombolytics (tPA, TNK)
there are numerous more....

The following would NOT qualify:

Monitorning blood glucose levels when giving SQ insulin. The intended effect of insulin is lowering the blood sugar
Monitoring for akathisias after giving reglan. Monitoring by history or examination does not qualify.

Risk of Complications and/or Morbidity and Mortality - High - Decision Regarding Hospitalization

Summary

Admitting or discharging a patient to a higher or alternate level of care qualifies as high risk.

Explanation

AMA Definition:

There is no explanation offered by the AMA.

ACEP Interpretation:

Admitting a patient to a higher level of care (Observation, Inpatient) can indicate high risk of morbidity and mortality. Additionally, a decision about hospitalization includes alternate levels of care (e.g. being discharged to a board and care) and as such also qualifies under this category.

warning Key Point:

A discussion to admit a patient that ultimately leads to discharge qualifies for this selection.

Generating a Critical Care Script

You can suggest a level of service critical care script (99291, 99292) for patients who required critical care services. The tool does not rely on any of the other selected values in the grid.

warning This tool only produces a level of service script, not the justification for critical care. You still need to document why you performed critical care time in your note.

Prior to 2023, the AMA CPT defined the time-based critical care services as

30 - 74 minutes --> 99291
75 - 104 minutes --> 99291 and 99292
105 - 134 minutes --> 99291 and 99292 x 2
135 - 164 minutes --> 99291 and 99292 x 3
165 minutes or more --> 99291 and 99292 x as appropriate (per above illustration)

these definitions were accepted and used both by CMS and private insurers.

In 2023, CMS (Centers for Medicare and Medicaid Services) will be instituiting their own new standard of submittable Critical Care Time. The 99292 threshold will not be considered complete until 104 minutes of Critical Care services has been provided.

Thus, under CMS, new pivotable marks will reside at 30 minutes, 104 minutes, and every 30 minutes thereafter. This change will cause uncertainty as to which payers will adhere to the old AMA CPT Critical Care thresholds and the new thresholds defined by CMS.

"Use 2023 CMS Time Brackets" The checkbox allows you to choose the old, existing AMA CPT time brackets or the new CMS time brackets. The 2023 CMS time brackets look like:

30 - 104 minutes --> 99291
105 - 134 minutes --> 99291 and 99292
135 - 164 minutes --> 99291 and 99292 x 2
165 minutes or more --> 99291 and 99292 x as appropriate (per above illustration)