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Teaching the New Ways: Improving Resident Documentation for the New 2023 Coding Requirements

Year: 2024

Type: article

Abstract: BACKGROUNDIn January 2023, significant changes to the structure of the Current Procedural Terminology CPT(R) evaluation and management (E/M) codes (here forward called the 2023 E/M changes) were implemented for emergency department (ED) encounters.These modifications aim to lessen administrative workload and accurately match coding with contemporary patient care practices.1 They are anticipated to impact roughly 85% of the relative value units of ED care 2 and, thus, also have significant financial implications for EDs.Residents provide front-line care and documentation for millions of patients seen in United States EDs annually.The Model of Clinical Practice of Emergency Medicine 3 identifies financial principles, such as billing and coding, to be required core content for board certification.Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) includes quality clinical documentation to be one of the milestones that determine advancement in residency training.4 Interventions that alleviate documentation burden are also associated with improved physician well-being per the existing literature.5 However, research suggests that most emergency medicine (EM) residents do not receive formal training in billing and coding and have knowledge gaps in this area.[6][7][8] Historically, documentation of encounters in the ED focused on the number of elements within history of present illness (HPI), review of systems (ROS), physical exam (PE), and medical decision-making (MDM).These new coding guidelines shift the focus almost entirely to MDM.They emphasize documentation of differential diagnoses; independent interpretation of medical testing; justification of testing not pursued; social determinants of health; chronic diseases; histories; communication with consultants, ancillary staff, and primary care; and review of external records.

Source: Western Journal of Emergency Medicine

DOI: 10.5811/westjem.21183