Name: Billing & the 2023 E/M rules — ER Toolkit
Creator: Kim Trinh, MD

Since 2023, the ED E/M level (99281–99285) is determined by medical decision-making alone — history and exam no longer count toward the level. The same note that defends you medicolegally is the note that supports the level your cognition actually earned. Most under-coding is under-documentation: the thinking happened, but the chart doesn't show it.

01The framework: three pillars, highest two win

The MDM level is set by the highest two of three pillars:

Problems addressed — the number and severity of conditions you evaluated, including the ones you ruled out.
Data reviewed and analyzed — tests, records, independent interpretation, and conversations with other clinicians.
Risk of management — the risk of the decisions you made, including the ones that ended in discharge.

Level 5 (99285) requires high complexity in two pillars; level 4 (99284) requires moderate in two. That's the whole skeleton — everything below is what "high" and "moderate" mean in an ED note.

02Problems: a ruled-out killer still counts

A problem "addressed" includes the life threat you evaluated and excluded. Chest pain worked up for ACS, PE, and dissection is a high-complexity problem — a potential threat to life or bodily function — even when every test is negative. But only if the note shows the threat was actually considered.

▼ reads as level 3

"Chest pain. ECG and troponin normal. Discharged."

▲ reads as what it was

"I evaluated this patient for chest pain. The differential included the life-threatening causes — acute coronary syndrome, pulmonary embolism, and aortic dissection…"

This is why the Workup opens every note by naming the differential: the same sentence that protects the patient supports the level.

03Data: three categories, and "reviewed" isn't "interpreted"

The data pillar counts three categories; extensive (level-5) data means meeting two of the three:

Category 1 — tests, documents, and sources: each unique test ordered or reviewed, external records reviewed, and an independent historian (family, EMS, caregiver) each count here.
Category 2 — independent interpretation: your own read of an ECG, radiograph, or other study — not billing for the formal read, and not "radiology report reviewed." Write what you saw.
Category 3 — external discussion: a direct conversation with another physician or qualified professional (consultant, PCP, transferring facility) about management.

The Workup's documentation toggles — "I independently interpreted the ECG…", "I corroborated the history with an independent historian…", "I discussed the case directly with…" — exist precisely because these sentences are the difference between data that counted and data that didn't.

04Risk: the discharge you almost didn't make

High-risk management includes the decision regarding hospitalization — which you make even when the answer is discharge. If you seriously weighed admitting, say so:

▼ invisible

"Discharged home."

▲ the decision, on paper

"I weighed admission against discharge for this patient. Given the workup above, the patient's clinical stability, and follow-up they can realistically access…"

Other high-risk anchors that are routine in the ED: parenteral controlled substances, drug therapy requiring intensive monitoring for toxicity, the decision about emergency major surgery, and de-escalation of care. Shared decision-making documentation supports risk too — it shows the risk was real enough to warrant a structured conversation.

05Level 4 vs level 5, in one breath

99285 (high): a threat to life/function evaluated plus either extensive data (2 of 3 categories) or high-risk management (e.g., the hospitalization decision).
99284 (moderate): an undiagnosed new problem with uncertain prognosis, moderate data (1 category met meaningfully), or moderate-risk management (e.g., prescription drug management).
The most common miss: a genuinely high-complexity workup documented so thinly it reads as a level 3. The cognition was there; the sentences weren't.

06Critical care is different

Critical care (99291) is time-based and sits outside the MDM grid: 30+ minutes devoted to a patient with a high probability of imminent, life-threatening deterioration. The attestation needs the total time (exclusive of separately billed procedures) and why the patient was critical. The dotphrases library has a critical-care attestation (.critcare-family) plus the resuscitation notes — .codenote, .intubation, .rosc — whose content is exactly what supports it.

07Where the toolkit does this for you

The Workup shows a live E/M support readout derived from what the note documents — never the other way around. Problems, data, and risk are inferred from your actual sentences.
The coding dotphrases (independent interpretation, independent historian, external records, consultant discussion, hospitalization decision, critical-care attestation, and friends) each add one pillar-supporting sentence in chart register.
Everything here is documentation of work actually performed — the level follows the cognition, not the reverse. Charting work that didn't happen isn't coding; it's fraud.

08Sources

AMA. CPT Evaluation and Management (E/M) Code and Guideline Changes, 2023. American Medical Association.
ACEP. 2023 Emergency Department E/M Guidelines FAQs. American College of Emergency Physicians.
CMS. Evaluation and Management Services Guide. Centers for Medicare & Medicaid Services.