Special Briefing: Introduction to

the 2023 CPT Documentation

Guidelines for ED E/M Services
Why the DGs were Revised, the Process and Rationale
David A. McKenzie, CAE
ACEP Reimbursement Director
In the beginning..
MEDICINE
Procedures
Emergency Department Services
New Patient
99500 Emergency department service, new patient, minimal
90505 brief service
99510 limited service
90515 intermediate service
90517 extended service
90520 comprehensive service
Established Patient (90530, 90540, 90550, 90560,90570, 90580)
 How did we get here?
AMA & HCFA release Revised
E&M section of CPT overhauled with all Documentation Guidelines for
new E/M codes. Evaluation and Management Services
to be effective January 1, 1998.

1988 1995 1998

1992 1997
Documentation Guidelines for E/M Services jointly developed
by the American Medical Association (AMA) and the Health
AMA, HFCA, CPT Editorial Panel, CPT Care Financing Administration (HCFA). 1998 E/M DGs postponed
Advisory Committee, the Practicing Physicians indefinitely. Physicians instructed
Advisory Council, and the Medicare Carrier to use 1995 DGs or 1997 DGs.
Directors begin work to revise or replace
existing E/M codes.
 How did we get here?
Draft 2000 E/M Documentation Guidelines released. Simplified version CMS announces plan to pay a single
of the 1997 DGs with reduced number of elements to be counted. blended for office E/M levels 99023
Never approved by HCFA. to 99204 starting in 2021.

1999 2015 2019

2000 2019
Draft 2015 E/M Documentation Guidelines – December
Revisions released. Never approved by HCFA.
AMA submitted “New Framework E/M AMA CPT Editorial Panel
Guidelines to HCFA for approval. New approves revisions to the Office
Framework DGs are easier to understand and or other outpatient visit reporting
easier to use with limited counting of elements. guidelines and code descriptors.
Never approved by HCFA.
 How did we get here?
CMS & AMA announce New E/M
New E/M guidelines for Office or Other Outpatient Guidelines will be applied to all E/M
codes 99202-99215 become effective January 1st. codes in 2023.

2020 2021 2023

2021 2022
New E/M guidelines for Office or Other Outpatient codes
99202-99215 revised / updated on March 9th.
CMS eliminates blended rate concept in favor New E/M Guidelines
of the E/M code revisions and new valuation effective January 1st.
data produced by AMA.
AMA CPT 2014-2015 Attempt at DG Reform
AMA Joint CPT/RUC Workgroup on E/M
Name CPT/RUC Specialty Other
Peter Hollman, MD RUC, AMA Alternate Representative Geriatric Medicine AMA HoD
Co-Chair CPT Editorial Panel, Former Chair
Barbara Levy, MD CPT Editorial Panel Member Obstetrics & Gynecology AMA HoD
Co-Chair RUC, Former Chair
Margie Andreae, MD RUC Member Pediatrics
Linda Barney, MD CPT Editorial Panel General Surgery
Patrick Cafferty, PA-C CPT Editorial Panel Member Physician Assistant
(Former)
Health Care Professionals Advisory Committee
(HCPAC)

Scott Collins, MD RUC Member Dermatology

David Ellington, MD CPT Editorial Panel Member Family Medicine AMA HoD
Former Member
Chair of Previous CPT E/M Workgroup
Chris Jagmin, MD CPT Editorial Panel Member Family Medicine
Medical Director, Aetna
Douglas Leahy, MD RUC Member Internal Medicine
Scott Manaker, MD RUC Member Pulmonary Medicine
Chair, PE Subcommittee
Robert Piana, MD CPT Editorial Panel Member Cardiology
Joint Workgroup Guiding Principles
The CPT/RUC Workgroup on E/M is committed to changing the current coding and
documentation requirements for E/M visits to simplify the work of the health care provider and
improve the health of the patient
To decrease the administrative burden of documentation and coding and align CPT and CMS
wherever possible
To decrease the need for audits
To decrease unnecessary documentation in the medical record that is not needed for patient
care
To ensure that E/M is resource based and there is no direct goal for payment redistribution
between specialties
AMA Joint CPT/RUC Task Force on E/M - ED Subgroup
None of This Happens Without These Guys
J. Mark Meredith, III, MD, MMM, FACEP, CPE, FACPE - Emergency Medicine CPT Advisor
Ten years of CPT service to date
Currently serves on the CPT Appendix P Work Group
Michael J. Lemanski, MD, FACEP, FAAFP - Emeregncy Medicine Alternate Advisor
Six years of CPT service to date
Currently serves on the CPT Assistant Editorial Review Board
Both attend 3 meetings a year for 4 to 5 days each all unpaid
Both volunteer untold hours reviewing CPT Code Change Applications from others
They are your voice in the AMA CPT process, with a great track record of wins
In my 28 years of leading the CPT delegation they are only the 3rd and 4th Advisors
To quote Greg Henry from 1996, “If either of these guys ever has to buy their own drink at an
ACEP meeting, there is something wrong.”
Emergency Department Recommendations to WG
Time should not be used as a key criterion for code selection
Agreed that history and physical exam should be removed as key elements for ED code selection
Initial recommendation to keep the current 5 levels
Will need to determine differentiator between 99283 and 99284
Both currently have Moderate MDM (only difference is History/Exam)
Recommendations for MDM alignment
99281 remove the concept of MDM (like for code 99211 in office visits)
99282 move from low to straight forward MDM
99283 move from moderate to low MDM
99284 keep moderate MDM
99285 keep as high MDM
Emergency Department WG Additional Discussions
Services in the ED by non-ED physicians:
• Recommended that language be that only one physician/QHP reports the ED service
• But if there was an ED physician involved, the other physician reports a different E/M code (office
or consult)

Use of the ED as a “courtesy room” is a meeting for convenience

• Recommended don’t report as an ED E/M visit. Report as an Office/Outpatient code

Multiple services by other physicians

• Recommended to follow the same rules from subsequent inpatient visits
• Report both E/M visits if involved
2022 CPT ED E/M Code Descriptor
2023 ED E/M Code Descriptors
• 99281 - Emergency department 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 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and straightforward medical decision making

• 99283 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and low level of medical decision making

• 99284 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and moderate level of medical decision making

• 99285 - Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and high level of medical decision making
CPT Appendix C Clinical Examples Will Not Appear in 2023
99281 - Removal of sutures from a well-healed, uncomplicated laceration
99282 - Rash on both legs after exposure to poison ivy
99283 - Inversion ankle injury unable to bear weight on the injured foot and ankle
99284 – Four-year-old who fell off a bike sustaining a head injury and brief loss of
consciousness
99285 - Patient with an acute onset of chest pain compatible with symptoms of acute cardiac
ischemia and/or pulmonary embolus
99291 – First hour of critical care for a 15-year-old with acute respiratory failure from asthma
ACEP is working on ED clinical examples that will illustrate the new code descriptors
Other 2023 CPT Code Set ED E/M Language
Time is not a descriptive component for emergency department levels of E/M services 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.
Missing in 2023 is the historic following sentence, “Therefore, it is often difficult for physicians to
provide accurate estimates of the of the time spent face-to-face with the patient.”
For procedures or services identified by a CPT code that may be separately reported on the
same date, use the appropriate CPT code. Use the appropriate modifier(s) to report separately
identifiable E/M services and the extent of services provided in a surgical package
If a patient is seen in the ED for the convenience of a physician or QHP, use the office or other
outpatient codes (99202-99215)
New Code Change Application to Further Refinement of 2023
DGs
• No changes permitted after the February CPT meeting finalizing the 2023 guidelines
• Any future changes will require a CCA deadline was June 14th to be included in the 2024 CPT
code set. ACEP’s CPT Team has submitted a proposal seeking additional changes more
favorable to ED use.
Our Potential Goals
• Add the concept of 2 or more uncomplicated illness or injuries to Moderate MDM
• Add the concept of 2 or more Acute complicated illness or injuries to High MDM
• Add discussion with patient or surrogate of decision not to perform diagnostic tests under
Moderate and High MDM
• Add discussion with patient or surrogate of advanced test results to category 3 under Moderate
MDM
• Add administration of parenteral controlled substances under High Risk
• Expand the decision regarding hospitalization to include more options (i.e., nursing home or
rehab)
2023 Proposed Rule ED E/M RVUS Post DG Implementation

2022 2023
Code 2022 Work 2023 Work 2022 PE 2023 PE 2022 PLI 2023 PLI
Total Total

99281 0.48 0.25 0.11 0.06 0.05 0.02 0.64 0.33

99282 0.93 0.93 0.21 0.21 0.10 0.10 1.24 1.24
99283 1.60 1.60 0.33 0.35 0.18 0.16 2.11 2.11
99284 2.74 2.74 0.54 0.57 0.28 0.30 3.56 3.61

99285 4.00 4.00 0.75 0.79 0.42 0.47 5.17 5.26

Will Observation Codes be Deleted in 2023?

• Yes, but not the concept of observation services

• Observation and Inpatient codes are being combined into one code
family
• Follows the construct of the Inpatient or Observation same day
admission and discharge codes 99234-99236
• Observation code families 99218-99220, 99224-99226, and 99217
will be deleted in 2023
• Watch for potential decreases in the combined code payments post
2023 final rule
• The concept of Observation service is not going away!
Questions?
David A. McKenzie, CAE
dmckenzie@acep.org