Duly Noted and Newly Coded

A year later, how are you managing the Current Procedural Terminology (CPT) code changes that the American Medical Association (AMA) mandated in 2023?

For the past 30 years, the documentation of patient medical records has followed the same format, with heavy emphasis on elements of the patient care experience for coding. After three decades, the AMA and CPT overhauled coding guidelines in 2023 with the goal of reducing medical coding burden for physicians and APCs by dropping less helpful, burdensome documentation and focusing more on what is felt to be the key portion of the chart: Medical Decision Making (MDM).   While these changes streamline documentation, the task of relearning the entire notation process may be daunting. It may be time for a refresh.

Think with Ink

ApolloMD recognized this challenge and developed a full library of resources for clinicians to utilize in learning the new documentation.

“It’s a new way of documenting what you’ve been doing all along – and when performing these tasks, documenting the thinking– tasks such as talking to a consultant, interpreting test results, and being specific about patient acuity.  These tasks indicate a higher level of service, and the AMA rules indicate these tasks reflect a higher level of service,” says Michael Lipscomb, MD, ApolloMD Chief Quality and Patient Safety Officer.

“One major benefit: Whoever is reading the record may follow the thought process of the physician or APC, instead of reviewing a medical chart and piecing together a narrative based on checkboxes and bullet points.”

Summary of Changes

Understanding the rules created by the AMA achieves the overall goals of accurate documentation, coding, and compliance. The 2023 CPT changes combine various elements to determine the E/M level of any given chart.

While MDM is now the main component of documentation, the reporting of patient history, review of systems, and physical exam remain very important to good patient care and to support the acuity level of the patient.

Click here to download a complete set of the guidelines.

A summary of the 2023 changes includes:

ACEP Special Briefing FAQs

The questions and answers below are copied from the ACEP Special Briefing FAQs document linked in the section title above. To view the complete document, please click the title or this link.


Are the review of systems, family history, and past history adding to the complexity, or will they be unnecessary in this new format?

History and exam don’t directly contribute to the E/M code, but a medically appropriate history and physical exam are still necessary. The MDM grid measures the complexity of problems addressed with expressive statements such as acute, uncomplicated illness or injury, undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; chronic illnesses with severe exacerbation. A descriptive history and exam will ensure the coder or auditor will understand the complexity of problems addressed to the extent necessary to determine medical decision-making accurately.


Can we use the R/O or Impressions in scoring the Number and Complexity of Problems Addressed at the Encounter?

Yes, physicians are often cautioned against documenting possible, probable, or rule-out diagnoses because these conditions cannot be used for ICD-10 coding in the emergency department or other outpatient settings. However, these rule-out conditions illustrate the significance of the complexity of the problems addressed and justify the work done, especially in situations where the final diagnosis seems less than life-threatening.

Per CPT: “The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to conclude that the signs or symptoms do not represent a highly morbid condition. Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition.”

Documenting possible, probable, or rule-out diagnoses reflects that the patient had “presenting symptoms that are likely to represent a highly morbid condition.”

Do the comorbidities need to be noted in the MDM or does mention of them in the HPI or PMH count?

Simply listing the comorbidity does not satisfy the CPT definition. The documentation should reflect how the comorbidities impacted the MDM for the ED encounter.

Per CPT: “Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”


The patient has had outpatient tests and is referred to the ED. If you review the test images/report, does that count? You did not order it, but you reviewed it. Similarly, the patient has had an outpatient lab, but you review the result rather than rely on the patient telling you the result.

Yes, review of tests ordered outside the ED count.

Regarding unique tests: If a basic metabolic panel is ordered, does that count as 1 test, or are the Na, K, etc., broken out individually? Or do we need to draw attention to the labs, such as saying Na 132, K 4.5, and thereby getting more than one point?

A lab panel is a single test. The CPT code set determines the differentiation between single or multiple tests. A BMP includes eight tests that each have their own CPT code but are reported as a panel with CPT 80047 and counted as one unique test in Category 1.


Could you elaborate further on “external” notes? Does that mean external to the organization or external to the ED?

External to the ED, notes from the same organization but from a physician in a different group, specialty, or subspecialty are considered external notes.


Does an independent interpretation of an X-ray need to happen before a radiologist completes their interpretation? Or can you document even if you review and interpret after their formal interpretation?

Yes, if the ED physician does an interpretation of the x-ray, that does count toward Category 2 even if there will be or has been an overread.

If telemetry monitoring was also interpreted/documented by the physician during the encounter, would that satisfy the independent interpretation of tests?

Yes, rhythm strip interpretation meets the requirement of having a CPT code, and an interpretation or report is customary.


If management is discussed over the phone by the sending provider – before the patient’s arrival (urologist sending for CT) – can that count as a category 3 data point?

Yes. CPT does stipulate that the discussion must be used in the decision-making of the encounter; a courtesy call as a “heads up” that the patient is on the way without offering some clinical insight on the patient’s condition may not meet the CPT definition.

Would text message count as a “discussion of management” to satisfy Category 3? Most of our communication with consultants at least starts with secure text messaging through our EHR. Sometimes, this is the only communication; it is back and forth, but it isn’t on the phone.

CPT requires a live interactive exchange; a real-time text chat would be the same as a phone call for the purposes of scoring the MDM. The issue is the content of the message. Reporting the CT result isn’t the same as discussing the patient’s images as part of the MDM process.

Click here to visit a common list of FAQs answered by the American College of Emergency Physicians (ACEP).

High-Level Thinking

While it’s the same basic coding language previously used, this updated application presents a new dialect, changing the focus of what’s important from bulleted notes into a high-level chart showing high-level thinking. The updated documentation methods require a paradigm shift, altering the perspective from which clinicians note patient interaction.

At the recent American College of Emergency Physicians (ACEP) Reimbursement and Coding Conference, ApolloMD Vice President of Patient Safety and Quality Laura Springer noted some of the common transition issues and felt that ApolloMD had a great handle on helping physicians and APCs understand the new documentation guidelines. “We’ll be developing additional resources to give the providers a clearer picture of what they should be documenting.”

While coding physician and APC documentation is ultimately determined by our coding partners, learning the new guidelines requires a multifaceted approach, including ApolloMD education to our providers.  Education is the best practice for ensuring exceptional performance by providing updated resources and information to all team members. Check back for additional updates on the new coding changes or feel free to reach out to the ApolloMD Quality Team directly at quality@apollomd.com.

Additional Resources

Download the 2023 Changes to the Hospitalist Evaluation and Management Codes.

ACEP “Regs & Eggs” blog article 10-13-2022: Major Documentation Changes are Coming in 2023 – Got Questions? ACEP’s Got Answers

Visit ApolloMD’s blog to stay up to date on the trending topics in health care.

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