emergency room visit low mdm

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Medical Decision Making

View full MDM levels/elements grid

Levels of MDM

The original four levels of MDM (straightforward, low, moderate, and high) have not changed for 2021. However, as codes 99201 and 99202 previously both described "straightforward" MDM and were differentiated only by history and/or exam elements, code 99201 will be deleted and E/M services previously reported using 99201 will be reported using 99202 beginning in 2021.

The table below shows the level of MDM for each office/outpatient E/M code.

MDM Element Titles

Each level of MDM continues to have the same three elements. For 2021, the titles of these three MDM elements have been revised to better reflect the medical decision making process. The table below highlights the revisions to the MDM elements titles effective January 1, 2021, for office/outpatient E/M codes.

The level of MDM for office/outpatient E/Ms continues to be based on 2 out of 3 elements.

Element 1: Problems Addressed

• The number and complexity of problem(s) addressed.

CPT defines a problem as "…a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter."

Element 2: Data Reviewed and Analyzed

• The amount and/or complexity of data to be reviewed and analyzed.

This element recognizes each unique test, order, or document to meet the requirements for each level of MDM. Tests can include imaging, laboratory, psychometric, or physiologic data. The difference between single or multiple unique tests is based on the applicable CPT code(s) for such tests. For example, CPT code 80047 describes a clinical laboratory panel that includes and requires multiple tests but is considered a single test because only one CPT code is reported.

Important for surgeons: Independent interpretation of a test performed by another physician and not separately reported by the surgeon (e.g., independent interpretation of a chest x-ray) meets a criterion for this element as "data analyzed." In addition, discussion of patient management (e.g., surgeon and physical therapist) or test interpretation with external physicians (e.g., surgeon and pathologist) meets a criterion for this element. However, external physicians cannot be in the same group practice or same specialty/subspecialty as the billing surgeon. For example, reviewing an image with your office partner would not count as a criterion for this element.

Element 3: Risk

• The risk of complications and/or morbidity or mortality of patient management.

CPT has developed an extensive definition for risk:

"The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. 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. 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, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization."

The MDM table provides examples of risk for moderate and high MDM that many surgeons can relate to, such as a decision regarding minor surgery with identified patient or procedure risk factors or a decision regarding elective major surgery without identified patient or procedure risk factors.

Download the Office E/M Coding Changes Guide (PDF)

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ED Charting and Coding: Medical Decision Making (MDM)

Editor’s note (jan 13, 2023): .

The new AMA CPT 2023 Documentation Guidelines have been published and the coding elements within the medical decision making section have been revamped. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines .

In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.

CMS Assessment of Medical Decision Making

The Centers for Medicare & Medicaid Services (CMS) evaluates MDM based upon the highest 2 of the following 3 elements:

• The number of diagnostic and management options to be considered
• The complexity of data analyzed, including charts, tests, and other sources (family, EMS)
• The risk of complications, morbidity, and mortality associated with the presenting problem(s) and subsequently with the procedures and management options for them.

These elements are presented qualitatively in the following table. See each section below for more quantitative scoring systems.

Let’s work through a sample case, and discuss how each section is documented and then scored.

Diagnostic and Management Options

Begin your MDM section with a summary statement of the patient encounter and list your differential diagnosis:

Scoring the number of diagnostic and treatment options is accomplished in most places using the “ Marshfield Clinic Scoring Tool ,” which is not officially part of the E/M guidelines nor endorsed by CMS or the AMA. The tool tries to infer complexity from the nature of the problem and the effort it will take to address it. The following tables show the tool and the most common conversion from Marshfield “problem points” to the E/M guidelines element for number of diagnostic and management options.

The tool was developed for clinic appointments, but the American College of Emergency Physicians (ACEP) has recommendations to adapt it to the emergency department (ED) setting. The first distinction is new vs established problems. In the ED, most patients present with problems that are new to the examiner, so unless you are caring for a patient on a planned return visit, your cases will either be minor, self-limited problems (1 point for each problem) or new medical problems that require consideration, guidance for care, and often some kind of workup (3 or 4 points for each problem). Contrasted to the clinic setting, where testing is typically done between visits, in the ED we order, perform, and interpret most of our tests during the visit. So any new problem you can diagnose and manage by history and physical exam alone will score 3 points, and those requiring testing to guide diagnosis and management will score 4 points, as in the case of Ms. Example.

Data Review

The body of your MDM will describe how you work through your differential. Decisions based upon your history and exam require minimal additional information, but cases that require chart review, tests, and images are credited for increasing complexity.

To score your data review, you may use a table to calculate “data points” for the different kinds of testing, interpretation, and record review. In the table below, note that different kinds of testing score separately, and if you are providing your own read (even if you have a radiologist, cardiologist, or pathologist also on record) you get credit for that work. It’s important to include your interpretation of test results, both as part of your thought process and because your input counts.

As a side note, ECG interpretation must include ≥3 of 6 elements:

• Rate/rhythm
• ST-segment changes
• Comparison to prior
• Summary of the patient’s clinical condition

You may also interpret the telemetry monitor recordings, which should include a mention of rate and rhythm.

We can also address the level of risk involved for the presenting problem, testing, and treatment plan. The following table gives examples for risk, based upon the categories of presenting problems, testing required, and treatment plans. Important to note: the highest single item in any category determines the level of risk ( CMS Evaluation and Management Services Guide, PDF ).

The differential diagnosis for RLQ pain in a 25-year-old woman includes causes at each level of risk, and you should tailor both your differential and your workup appropriately to the presenting problem. Failure to account for higher-risk diagnoses, perform adequate testing, and appropriately escalate care are major areas of potential liability for EM providers. For Ms. Example, if you limited your workup to cystitis and ovarian cysts, this would be minimal to low risk . Considering pelvic inflammatory disease (PID) or other serious infection is  moderate risk . Being appropriately concerned for appendicitis, peritonitis, and ovarian torsion reaches high risk . Non-invasive testing (labs and radiology) is considered low risk , but use of IV opioids to treat pain places the management level at high risk (drug therapy requiring monitoring).

Our sample case demonstrates High Complexity MDM based upon extensive diagnostic and management options , extensive data review and analysis , and high risk . It was quite thoroughly documented, but the scoring could be accounted for with just two items: a new problem requiring testing and pain treated with IV narcotics.

Work Smarter, Not Harder: Show Your Effort

The MDM is arguably the most important section of the patient’s record. There are many styles of documentation depending on your system, our example reflects the style we have adopted since using computer dictation, and many will be much shorter. Regardless, every MDM should include 3 core elements:

• Explain the complexity of the diagnostic and management options available to you by giving a brief summary of your patient’s presentation followed by your differential diagnosis, no matter how short.
• Describe and interpret the data that you obtained and reviewed. Be sure to use a phrase such as, “on my interpretation,” when you independently interpret radiographs or ECGs and briefly summarize prior visits that you reviewed.
• Be sure to mention the risk the patient is at due to their underlying pathology, the testing that is required to make a diagnosis, and the treatments that you administer or prescribe.

This example demonstrates the core elements of the MDM up to the point of admission for billing purposes, but leaves out the greater proportion of charts you will write: discharges. Documentation of discharge planning, return precautions, and unplanned discharges including those leaving against medical advice (AMA) and risk-minimizing measures will be covered in a future post.

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2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a 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.

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Explore This Issue

The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

• 99281: ED visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
• 99282: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• 99283: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
• 99284: ED visit for the evaluation and management of a patient which requires a medically appropriate history and/or examination and moderate medical decision making.
• 99285: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

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Getting clear on the new coding rules can help you eliminate bloated documentation and improve reimbursement to reflect the value of your visits.

THOMAS WEIDA, MD, FAAFP, AND JANE WEIDA, MD, FAAFP

Fam Pract Manag. 2022;29(1):26-31

Author disclosures: no relevant financial relationships.

In 2021, significant changes were adopted for the documentation guidelines for outpatient evaluation and management (E/M) visit codes. Most notably, medical decision making or time became primary drivers of visit level selection, rather than the number of history and physical exam bullets.

In this article, we review the context for these changes, describe them briefly, and offer a quick reference tool to help physicians apply the new rules in practice.

The revisions to the E/M outpatient visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements.

Code level selection is now simplified — based on either medical decision making or total time.

The authors' one-page coding reference tool can help simplify the new rules.

HOW WE GOT HERE

In the 2019 Medicare physician fee schedule final rule, released in November 2018, the Centers for Medicare & Medicaid Services (CMS) adopted revisions to the outpatient E/M codes in order to reduce administrative burden. (See https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year .) Originally scheduled for implementation in 2021, these changes would have combined visit levels 2–4 into a blended payment rate (e.g., one rate for 99202-99204 and one rate for 99212-99214), among other changes.

In response, the American Medical Association (AMA) convened a joint CPT Editorial Board and Relative Value Scale Update Committee (RUC) workgroup to build on the changes and propose some alternatives. The workgroup's goals were to decrease administrative burden, payer audits, and unnecessary medical record documentation while ensuring that payment of E/M services is resource-based.

The workgroup approved significant revisions to the outpatient office visit E/M codes. Code 99201 was deleted. The history and/or physical examination and the counting of bullets were eliminated as components for code selection (although history and/or physical examination documentation should still be performed as medically appropriate). Medical decision making (MDM) or time could be used for code level selection. Changes were made to the code descriptors for 99202-99205 and 99211-99215, the definition of medical decision making, and the calculation of time, and a shorter prolonged services add-on code was created. CMS adopted these new E/M coding guidelines. As a result of the changes to medical decision making and time-based coding, the RUC revised the 2021 relative value units (RVUs) for office visit E/M codes. Most of the values increased, yielding an overall increase of more than 10%.

CODING BASED ON MEDICAL DECISION MAKING

For outpatient E/M coding, medical decision making now has three components:

Number and complexity of problems addressed at the encounter,

Amount and/or complexity of data to be reviewed and analyzed,

Risk of complications and/or morbidity or mortality of patient management.

There are four levels of decision making for each of these components: straightforward, low complexity, moderate complexity, and high complexity.

To determine the level of code for a visit, two of the three components must meet or exceed that level of coding. ( See the table .) For example, if the patient has multiple problems addressed at the encounter, but the data is limited and the risk of complications is low, then the level of medical decision making would be low. New patient codes 99202-99205 and established patient codes 99212-99215 use the same components and levels of decision making for code selection.

Determining medical decision making usually starts with identifying the number and complexity of problems addressed and then determining the data or risk components that support that medical decision making. If a second component does not meet or exceed the problem component, then a lower level of decision making is appropriate. The set of tables below illustrate the essential concepts of these code levels. Each level has specific criteria for each component.

Straightforward medical decision making: Codes 99202 and 99212 include one self-limited or minor problem with minimal or no data and minimal risk.

An example of a 99202 or 99212 is an otherwise healthy patient with cough and congestion due to the common cold.

Low complexity medical decision making: Codes 99203 and 99213 include two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury.

The data component requires one of two categories to establish the level. Category 1 data requires at least two items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, or each unique test ordered. Tests include imaging, laboratory, psychometric, or physiologic data. A clinical lab panel, such as a complete blood count, is a single test. Of note, if a test is ordered, the review of that test is included with the ordering, even if the review is done at a subsequent visit. Tests ordered outside of an encounter may be counted in the encounter in which they are analyzed. Category 2 data includes significant history given by an independent historian. Parents giving the history for their child is a typical example.

The risk component is low. There is low risk of morbidity from additional diagnostic testing or treatment.

An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.

Moderate complexity medical decision making: Codes 99204 and 99214 include two or more stable chronic illnesses, one or more chronic illnesses with exacerbation, progression, or side effects of treatment, one undiagnosed new problem with uncertain prognosis, one acute illness with systemic symptoms, or one acute complicated injury. A patient who is not at a treatment goal, such as a patient with poorly controlled diabetes, is not stable. Systemic general symptoms such as fever or fatigue in a minor illness (e.g., a cold with fever) do not raise the complexity to moderate. More appropriate would be fever with pyelonephritis, pneumonitis, or colitis.

The data component requires one of three categories to establish the level. Category 1 data requires at least three items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, each unique test ordered, or independent historian involvement. Physicians cannot count tests that they or someone of the same specialty and same group practice are interpreting and reporting separately (e.g., electrocardiogram, X-ray, or spirometry). Category 2 data includes the independent interpretation of a test performed by another physician/other qualified health care professional (QHP) (not separately reported). For instance, if a chest X-ray was ordered and the ordering clinician included the interpretation in the visit documentation, this would qualify for data point Category 2. However, if the ordering clinician bills separately for the interpretation of the X-ray, then that cannot be used as an element in this category and would be an element for Category 1. Category 3 data includes discussion of management or test interpretation with an external physician/QHP (not separately reported).

The risk component may include prescription drug management, a decision for minor surgery with patient or procedure risk factors, a decision for elective major surgery without patient or procedure risk factors, or social determinants of health (SDOH) that significantly limit diagnostic or treatment options, such as food or housing insecurity. For prescription drug management, renewing pre-existing chronic medications would qualify. Documentation that the physician is managing the patient for the condition for which the medications are being prescribed would help establish validity in the use of this criterion for MDM.

An example of a 99204 or 99214 is a patient being seen for follow-up of hypertension and diabetes, which are well-controlled. An example using SDOH would be a patient with chronic knee pain and a positive anterior drawer test who needs imaging of the knee but cannot afford this care. Documenting that the patient cannot afford to obtain an MRI of the knee at this time, which significantly limits your ability to confirm the diagnosis and recommend treatment, adds to the risk component.

High complexity medical decision making: Codes 99205 and 99215 include one or more chronic illnesses with a severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function.

The data component requires two of three categories to establish the level. These data categories are the same as those for 99204 and 99214, and they follow the same rules.

The risk component may include drug therapy requiring intensive monitoring for toxicity. Decisions regarding elective major surgery with patient or procedure risk, emergency major surgery, hospitalization, or “do not resuscitate” orders are also high risk. Intensive prescription drug monitoring is typically supported by a laboratory test, physiologic test, or imaging, and is done to evaluate for complications of the treatment. It may be short-term or long-term. Long-term monitoring is at least quarterly. An example would be monitoring for cytopenia during antineoplastic therapy. Monitoring the therapeutic effect of a treatment, such as glucose monitoring during insulin therapy, is not considered intensive prescription drug monitoring.

An example of a 99205 or 99215 is a patient with severe exacerbation of chronic heart failure who is admitted to the hospital.

CODING OUTPATIENT E/M VISITS

Time-based coding.

An alternative method to determine the appropriate visit level is time-based coding. A major change is that total time now includes both face-to-face and non-face-to-face services personally performed by the physician/QHP on the day of the visit. Additionally, time-based coding is no longer restricted to counseling services. Instead, it includes the following:

Preparing to see the patient (e.g., reviewing external test results),

Obtaining and/or reviewing separately obtained history,

Performing a medically appropriate examination and/or evaluation,

Counseling and educating the patient, family, or caregiver,

Ordering medications, tests, or procedures,

Referring and communicating with other health care professionals (when not separately reported),

Documenting clinical information in the electronic or other health record,

Independently interpreting results (not separately reported with a CPT code) and communicating results to the patient, family, or caregiver.

Care coordination (not separately reported with a CPT code).

Time spent by clinical staff cannot count toward total time. However, time spent by another physician/QHP (not a resident physician) in the same group can be included. If a nurse practitioner performs the initial intake and the physician provides the assessment and plan, both of those times can be counted, although only one person's time can be counted while they are discussing the case with each other. The visit should be billed under the clinician who provided the substantive portion (more than half) of the time, although both clinicians need to be identified in the medical record. Time spent must be documented in the note. It is advisable to specifically document the time spent and the activities performed both face-to-face and non-face-to-face.

The amount of total time required for each level of coding changed under the new time-based coding guidelines. (See the “Total time ” table.)

PROLONGED VISIT CODES

When time on the date of service extends beyond the times for codes 99205 or 99215, prolonged visit codes can be used. The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. These are added in 15-minute increments in addition to codes 99205 or 99215. Code G2212 can be added once the maximum time for 99205 or 99215 has been surpassed by a full 15 minutes, whereas code 99417 can be added once the minimum time for 99205 or 99215 has been surpassed by a full 15 minutes. Less than 15 minutes is not reportable. Multiple units can be reported. Prolonged visit codes cannot be used with the shorter E/M levels, i.e., 99202-99204 and 99212-99214. (See “Prolonged services ” tables.) Clinicians should consult with individual payers to determine which code to use — G2212 or 99417.

SIMPLIFIED CODING AND DOCUMENTATION

The revisions to the outpatient E/M visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements. Only medically appropriate documentation is required. Code level selection is simplified — based on either medical decision making or total time. By applying these changes, primary care clinicians can eliminate bloated documentation and improve reimbursement reflecting the value of the visit.

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