New York American College of Emergency Physicians

Robert M. Bramante, MD FACEP

Robert M. Bramante, MD FACEP

Chairman, Emergency Medicine Mercy Medical Center Progressive Emergency Physicians

Making Sense of 2023 MDM Documentation

The move from paper to the electronic medical record (EMR) was a monumental change in the practice of medicine and documentation. Looking back at that change it was like a slow-moving storm that rolled over the country’s emergency departments and through healthcare infrastructure and that change currently, and will continue to, roll through our health systems as vendors change, systems change software and upgrades are made. With each twist, addition, upgrade or downtime session we experience changes to how we document in the EMR. If the move to electronic documentation was a slow rolling storm over years, the change with the 2023 Documentation of Evaluation and Management guidelines are a tsunami hitting the physician workforce across the country all at once. The previous guidelines have provided a framework for documentation that the current Emergency Medicine workforce has used for most of our, if not our entire, careers.

We committed to memory, taught and structured EMR templates around the 4+ history of present illness (HPI), 10+ review of systems (ROS), 2+ past medical/ family/ social history (PFSHx), 8+ physical exam (PE) items, and a high level of medical decision making (MDM) for the chart to potentially be coded as level 5 E&M visit. The last part, MDM was somewhat vague but included three essential categories, diagnoses, data and risk.

The tsunami that came to documentation made landfall in January 2023. The 2023 E&M documentation and coding guidelines all but eliminated the requirements for HPI, ROS, PFSHx and PE documentation. Instead, the requirement for this portion of the record is now a medically appropriate history and physical examination (More on the importance of this later). While that is intentionally vague, it is because the new guidelines are focused on the MDM portion of the chart as a means for calculating, coding and communicating the thought process of the physician in patient care. The three essential categories of MDM remain with slight modification. The number and complexity of problems addressed (COPA) – “diagnoses”, the amount and complexity of data addressed and reviewed – “data”, and risk of complications and morbidity/ mortality of the patient – “risk”. Critical care documentation remains essentially the same outside the required timing of critical care beyond the first 74 minutes (for documentation the physician should just clearly document the amount of time spent on critical care during the encounter to allow for appropriate coding). (ACEP MDM Grid)

When looking at the first category, COPA, it is important to recognize the problems and considerations addressed are independent of the final established diagnosis. This allows for the thought process on developing and eliminating a list of differential diagnoses considered. The key here is the high-risk condition does not need to be listed in the final diagnosis. The evaluation, work up or thought process should occur as part of the record. While “rule-out” items cannot be utilized for ICD-10 coding, documenting them can contribute to the complexity of problems addressed. Another important element that counts toward the COPA category is documenting the thought process around eliminating a differential or choosing not to do a test based on a risk score. Examples include not doing a pediatric head CT after utilizing PECARN and the HEART Score for determining the workup in chest pain, among many others. One last item related to COPA documentation, while there are not specific history and physical documentation elements required, a descriptive history including “acute” items, chronic items with “severe” exacerbation or noting systemic systems can contribute to the overall complexity.

The amount and complexity of data category, while more complex as it is broken up into three different sections to be met, has less ambiguity in how it is calculated. To achieve credit for this category in the highest E&Ms, documentation must meet two of three sections in this element. The first section includes tests, documents and independent historians. Two to three of these (with each prior external note or test ordered counting as individual points) need to be noted depending on level from limited to extensive. An important note is the ordering and review of a laboratory test is considered one item, however reviewing tests from outside or another physician can count separately. Of note, consulting the prescription monitoring database is a valid external record counting to this section. To achieve the highest coding the physician must also complete another section in this category, either independent interpretation of tests (not otherwise billed by the physician) and/ or discussing the case with another physician or qualified health professional. The physician should document their interpretation of ECG (if that physician is not billing that interpretation separately), rhythm strip, and/ or imaging should be noted but does not have to be documented as a formal report. The discussion section can include interactive exchange with a physician, qualified healthcare provider, facility (i.e.: hospital or nursing home) staff, or other appropriate professionals involved in the care of the patient (i.e.: lawyer, police, case manager), but does not include the family or informal care providers. For the items of discussion with other providers, review of prior records or use of an independent historian there should be notation of what occurred, information obtained and/ or pertinence to the current situation.

The risk category provides more physician discretion and is based on the usual behavior and thought process of the physician or a similar physician. While examples are available for moderate and high-risk including things like prescription drug management, social determinants of health, decision regarding hospitalization and parental controlled substances, it should be noted this list and the general list of examples is not exhaustive of potential risk items in all clinical situations. Even procedures or injuries considered minor in most populations can be high risk in patients with co-morbidities. As for the social determinants of health qualifier, the existence, alone, of one is not a risk qualifier.

The physician should document how the existing social determinant limits diagnosis or treatment. Some procedures noted to include risks are torso radiographs due to radiation exposure, IV fluids and non-IV contrast CT imaging in the moderate level. An ACEP publication has noted IV contrast administration is likely high risk (ACEP MDM FAQs). Decisions regarding major surgery or high-risk procedure include the common things we would think of in emergency medicine; CPR, central/ arterial access, thoracostomy, and intubation among others but it also includes procedures like IO placement, displaced fracture care, and intermediate/ major joint reductions. Most of us are not accustomed to documenting the complexity of our thought process, especially when an action or order is not performed. However, this is critical in this category as risk is defined by the consideration and decision process. Examples include consideration of admission for an asthmatic patient who receives treatment and subsequently improves and has good follow up not requiring hospitalization or the family who prefers to take an elderly patient home to avoid a hospitalization. The key is your thought process must be in the record. Other examples include the decision based on the physician’s assessment and risk benefit analysis on not ordering certain tests, controlled substances, or further workup.

None of this changes or absolves you of the medico-legal aspects of documentation. Specifically documenting family history may not change your MDM billing, however if it is pertinent to the complaint and if not noted that can create a situation of medicolegal risk. This is where the medically appropriate history and physical documentation become important. Despite the HPI/ ROS/ PMFSHx/ PE documentation not counting towards billing, these items can be critically important in the defense of a case. Additionally, lack of documentation of the thought process can potentially create questions as to the thoroughness of workup and treatment of the patient.

Overall, while changing and adjusting has been a challenge and has shifted coding distribution in many practices, the move away from a list of clicks and checks is probably better for patient ongoing care. It brings us away from being data entry clerks. As physicians, we now are not only getting credit for doing but for showing our work and thought process. For now, we will continue to adjust to this before further changes come as the documentation regarding split shared services is next up for change in 2024 after a one-year delay in implementation.