Emergency Medicine Documentation and Billing Changes for 2023 in the United States
Jessica Mason and Jason Adler
- The American Medical Association released updated guidelines for evaluation and management. The Current Procedural Terminology (CPT) documentation guidelines go into effect in the United States on January 1, 2023.
- The last update was in the 1990’s
- Why does this matter?
- It determines the level of service you provide which changes how we chart and how we get reimbursed.
- Overview of what is changing:
- There is no longer a minimum number of required elements for history and exam to meet billing criteria.
- History and exam should be medically appropriate.
- If the patient can’t provide history then documentation from EMS, family, caregivers, etc is scored towards complexity of medical decision making
- Charting elements that are valued in the new guidelines:
- Differential diagnosis reflecting the complexity of care
- Comorbidities that add complexity to management
- External chart review (including any records outside of the treating emergency department)
- History obtained by an independent source (eg. family, EMS, law enforcement, etc.)
- Discussions of management (eg. physicians, social work, pharmacists, etc)
- Independent interpretation of studies
- It is recommended to use the specific phrase “independent interpretation.”
- Diagnostic tests and medications considered but not ordered
- Social determinants of health that affect care
- Shared decision making
