Medical decision making simplified in 2023 - Diagnoses addressed

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Q: Can you please review the 2023 Evaluation and Management (E/M) new diagnoses definitions for medical decision making? I am learning to review charts, and I want to make sure that I’m interpreting these correctly.

A: Starting January 1st, 2023, providers must follow the 2023 Evaluation and Management (E/M) guidelines for dates of service across all places of service, including inpatient, observation, discharge, and consultation E/M services based on either time or medical decision making. We’ll focus on medical decision-making (MDM) for selecting a service level.

The MDM elements associated with E/M services consists of three components:

1. Diagnosis(es) - The number and complexity of diagnosis(es) addressed at the visit.
2. Data - Amount and/or complexity of data reviewed and analyzed at the visit.
3. Risk - Risk of complications and/or morbidity or mortality of patient management.

To select the level of an E/M service, two of the three elements must be met or exceeded. In this article, we’ll review the diagnoses, and we’ll cover the data and risk in subsequent articles.

The number and complexity of problems addressed at the encounter is divided into four levels.Each level has specific criteria for the conditions addressed, and it’s important to review the updated definitions for 2023.

New 2023 definitions and clarifications for diagnoses

We need to recognize how the AMA defines different types of illness to select the appropriate level of MDM and E/M code. Those definitions that have changed are listed below.

Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient.

Stable, acute illness: A problem that is new or recent and for which treatment has been initiated. Patient may be improved and stable, but resolution is not yet complete.

Example: Respiratory infection under treatment and monitoring for resolution.

Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity requiring treatment. Treatment requires hospital inpatient or observation setting.

Example: Uncomplicated appendicitis.

Chronic illness with exacerbation, progression, or side effects of treatment: Includes an intent to control progression and requires additional supportive care or attention to treatment for side effects.

Example: Progression during cancer treatment; Proctitis during radiation treatment for prostate cancer.

Chronic illness with severe exacerbation, progression, or side effects of treatment: Carries a significant risk of morbidity and may require an escalation in the level of care.

Example:Malignant pleural effusion requiring indwelling pleural catheter, patient with ovarian cancer with abdominal carcinomatosis undergoing chemo presenting with acute colonic obstruction.

Acute or chronic illness or injury that poses a threat to life or bodily function: Associated with illness or injury that poses a threat to life or bodily function in the near future without treatment. This can include symptoms that may indicate a condition which poses a potential threat to life and bodily function but work up and management of the symptoms must be associated with this level of severity.

Example: Pulmonary embolism, stroke, myocardial infarction, anaphylaxis.

For additional definitions and clarifications, refer to the section entitled Number and Complexity of Problems Addressed at the Encounter in the AMA’s CPT® Evaluation and Management (E/M) Code and Guideline Changes.

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.