As we closed the first month of the new 2023 E/M Coding Guidelines for emergency medicine, a number of identified issues arose which will require provider attendance to documentation details on a much larger scale. We noted at some facilities a drop in the percentage of 99285’s that could not be fully offset by the increase in 99283’s. So, now is a great time to recap what is required for 99285!

Nature of Presenting Problem:

1 or more chronic illnesses with severe exacerbation, progression, or sides effects of treatment

Amount and/or Complexity of Data to be Reviewed and Analyzed – Extensive

(Must meet the requirements of a least 2 of 3 categories)

Category 1:  Tests, documents or independent historian(s) 

Any combination of 3 from the following:

• Review of prior external note(s)from each unique source;
• Review of the result(s) of each unique test;
• Ordering of each unique test;
• Assessment requiring an independent historian(s)

Or

Category 2: Independent interpretation of tests

• Performed by another physician/other qualified health care professional (not separately reported);

Or

Category 3: Discussion of management or test interpretation  

Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

High risk of morbidity from additional diagnostic testing or treatment  

Examples only:

• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization or escalation of hospital-level care
• Decision not to resuscitate or to de-escalate care because of poor prognosis
• Parenteral controlled substances

 

Documentation Tips:

 

Some Documentation Take-Aways

• Do document differential diagnoses from which the final diagnosis is selected;
• Do document any social determinants of heath that may affect your treatment, disposition, patients ongoing health, etc.
• Do document the details of your discussions (interactive exchange) with other emergency physicians.  Discussions with external physicians (from other specialties/other practices) should also be detailed in your documentation.
• Do reference any analysis (included in the thought processes for diagnosis, evaluation, or treatment) of a test vs. interpretation unless interpretation is coded separately. Any test or interpretation coded separately is NOT included in the E/M code level.
• Do provide content of any discussion with family, friends, caregivers, etc. (eg, parent, guardian, surrogate, spouse, witness who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis)
• Do develop rule-out/rule-in discussion from HPI/CC/Test results.
• Do use adjectives to describe patient condition, reasons for additional care, etc. (severe, significant, high risk, limited mobility, serious, altered, etc.
• Do remember to document time managing patient care for critical care.
• Do address any additional problems you identify and discuss how they are being managed e.g. diagnostic studies, differential dx, discussion with other providers, etc.
• Do not reference review of tests not ordered or performed, e.g. “ I have reviewed all tests and have discussed with patient and/or family.” Avoid generalized or templated statements if they are not pertinent or accurate.