2023 Documentation Guidelines Components/Tips

* A “medically appropriate” history and physical - This should accurately represent your patient’s presentation & provide a rationale for your medical decisions for evaluation and management (E/M) 

* Medical Decision Making (MDM) - This is the driving influence on the CPT code selection for the E/M level of service (LOS) you document. MDM has 3 components with the LOS based on 2 of these being met. Focus on appropriately documenting the objective items listed in the first two components (COPA & Data) since much of the meaning of Risk in the 2023 documentation guidelines is unclear/subjective.

  1. Number & Complexity of Problems Addressed (COPA) during the encounter:

    Important distinctions between levels of service will be shown by the appropriate use of specific descriptive phrases. Additionally, documentation of the use of a risk calculator to determine the need for additional testing or treatment is an indicator of the complexity of the problems addressed.

    Moderate: 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; 1 undiagnosed new problem with uncertain prognosis; 1 acute illness with systematic symptoms; 1 acute complicated illness. Comorbidities only increase MDM if they are addressed during the encounter.

    High: 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; 1 acute or chronic illness or injury that poses a threat to life or bodily function.

  2. Amount &/Or Complexity of Data to be Reviewed & Analyzed:

    Combinations of data reviewed count towards higher levels of MDM. Specifically document your ordering, review, or discussion of the following:

    - Independent history because the patient was unable to provide sufficient detail or you needed to confirm the information the patient provided

    - Review of notes from outside your group/specialty (e.g., EMS run sheet, PCP, urgent care, nursing home, previous inpatient admission, etc.)

    - Documentation of tests or studies that you ordered or reviewed, including those you considered but ultimately did not order.

    - Independent interpretation of any non-lab study (e.g. rhythm strip, EKG, x-ray, CT or US)

    - Discussion of the studies/test/management of the patient's care with others outside your group/specialty (PCP, hospitalist, consultant, SWS)

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  3. Risk of Complications/Morbidity/Mortality of patient management decisionsmade regarding the patient's problem(s), diagnostic procedure(s) and treatment(s):


    - Rx/Rx management/review

    - Decision(s) to do or not do minor surgery/procedures (e.g. laceration repair, foreign body removal, incision and drainage, etc.)

    - Any social determinants of health that significantly limit the diagnosis or treatment (e.g. homelessness, insufficient social insurance, housing instability, economic circumstance, low income or unemployment, lack of primary support group, living in a residential institution, lack of transportation, etc.)


    - Drug therapy requiring extensive monitoring beyond history/exam - Parenteral controlled substances

    - Decision(s) to do or not to do major surgery/procedures (e.g. chest tube, cardioversion, fracture/dislocation reduction, etc.)

    - Decision regarding de-escalation of care due to poor prognosis

    - Any consideration for escalation of care or admission of the patient, even if ultimately the level of care was not escalated and the patient was discharged (e.g. Observation, close follow-up, outpatient PT/OT)

    Stable: For the purposes of categorizing comorbidities in the MDM, stable is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable even if the condition has not changed and there is no short term threat to life or function.

    Split/shared services for 2023: The shared visit must be reported by the physician, NP, or PA who has performed the substantive portion of the visit. For ED patients the substantive portion is defined as documenting in its entirety either the history, exam, or MDM portion of the note.

    Have questions about these guidelines? Ask at pettigrewmedical.com/contact-us/