Comparing 2023 CPT® E/M with Documentation Guidelines

EM Coding Guidelines

The 1995 and 1997 Documentation Guidelines and the 2023 CPT® E/M Services Guidelines are not drastically different when compared side by side.

Some hospitals and coding and billing entities may believe that the new 2023 CPT® evaluation and management (E/M) services guidelines and code changes simplify the coding, billing, and auditing processes. However, it is evident to me that the American Medical Association’s medical decision making (MDM) grid serves as a general framework for each level of service. Providers still need to provide specific information within the grid to offer a clear understanding to coders, billers, auditors, and payers. This task is not as straightforward as it appears and is highly subjective.

Although uncertainties persist regarding the 2023 E/M services guidelines, they are currently in effect. The Centers for Medicare & Medicaid Services’ (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services (’95/’97 DGs), including the table of risk, are no longer utilized.In this article, we will examine the components of MDM and organize them to enhance the intuitive selection of E/M codes.

Releated articles

E/M Guidelines Require A Different Approach to Documentations
New E/M Billing Guidelines for Unreimbursed Services

Exploring the Connection Between CPT® Risk Description and the 2023 MDM Grid

In the selection of an E/M service level, one factor taken into consideration is the risk involved. CPT® defines the risk of complications, morbidity, or mortality associated with patient management or treatment during an encounter as “management and treatment” risk. This is distinct from the risk level associated with the “condition of presenting problem(s)” or the “number and complexity of the problem(s) to be addressed” (NCOPA). Hence, there are two components of risk related to the patient: management/treatment risk and condition risk.

To provide a visual understanding of these risk indicators, below is a comparison between the 2023 E/M MDM grid and the table of risk from the ’95/’97 DGs. This comparison demonstrates how these elements align with the various levels of patient risk that may arise in different presenting problem scenarios.

Analyzing the Disparity between the 2023 E/M MDM Grid and Risk Table

 The two tables presented below contain identical information, with the only distinction being the additional content highlighted in the 2023 MDM grid for low MDM.

2023 Low MOM Column 1/Row Elements   Column 1/Row DG’s Table of Risk
“Condition Risk11”

Number and Complexity of Problem(s)

Addressed – Low MOM (e.g., 99283)

  • 2 or more self-limited or minor problems;or
  • 1 stable chronic illness;or
  • 1 acute uncomp licated illness or injury;or
  • 1 stable acute illness;or
  • 1acute uncomplicated illness or injury requiring hospital inpatient or obser vation level of care

The last two bullets are new for 2023.


Condition Risk” Presenting Problems -Low

  • Two or more self-limited or minor problems
  • One stable chronic illness
  • Acute uncomplicated illness or injury


2023 Low MOMColumn 2 Data Elements Columns 2 and 3 of DG’s Table of Risk
“Management and Treatment Risk”

Amount and/or Complexity of Data to Be Reviewed and Analyzed – Low MDM (e.g.,99283)

Limited – Must meet the requirements of at least 1 out of 2 categories

Categor y 1: Tests and documents

  • Any combination of 2 from the following 3:

Review of prior external note(s) from each unique source

Review of the result(s) of each unique test

Ordering of each unique test,


  • Categor y 2:Assessment requiring an independent historian(s)
“Management and Treatment Risk”

Diagnostic Procedures Ordered and Management Options Selected – Low Risk

  • Physiologic tests not under stress
  • Non-cardiovascular imaging studies with contrast           –
  • Skin and superficial needle biopsies
  • Lab tests requiring arterial puncture
  • OTC drugs
  • Minor surgery with no identified risk factors
  • IV fluids without additives
  • Physical and occupational therapy


Up to this point, the level of risk has been determined if the patient presents with any of the conditions mentioned on the left. However, the CPT® guidelines do not provide specific risk examples for low MDM, and the classification of the presenting problem(s) has not been assigned yet. Nonetheless, it should be noted that this does not imply that there are no examples that could fall into any of these categories.

Taking into consideration the emergency department (ED) E/M context, the American College of Emergency Physicians (ACEP) has indicated that ED groups are unlikely to utilize the low-risk code. This is because the conditions typically treated at this level are uncommon in such a setting and can be evaluated without the need for X-rays, testing, or imaging. As a result, it is highly likely that the distribution of E/M levels within ED groups will undergo a significant shift towards higher levels. This shift may raise concerns, leading to increased scrutiny and potential audits in the future.

Now, let’s delve deeper into the topic and examine the second or center column of the 2023 MDM grid. We will explore how risk is determined through the process of data collection.

The combined Columns 2 and 3 of the DG’s table of risk provide information on management and treatment risk options, as well as the potential data to be collected, such as diagnostic studies, ordered tests, reviews, interpreted results, discussions, and more. It’s important to note that CPT® does not include any risk examples specifically listed under the low-risk level.

Upon reviewing the MDM grid information on the left side, it becomes evident that imaging, testing, and other studies are factors that can be taken into account. It is my expectation that CMS will provide further guidance on this matter in future rulemaking.

Moreover, the 2023 E/M Services Guidelines for MDM offer risk examples for both the 99284 and 99285 levels of service. Now, let’s shift our attention to analyzing the moderate level of MDM (99284).

2023 Moderate MOMColumn 1 Elements Column 1 OG’s Table of Risk
“Condition Risk”

Number and Complexity of Problem(s) Addressed – Moderate MOM (e.g.,99284)

  • 1 or more chronic illnesses with exacerbation…,or
  • 2 or more stable chronic illnesses,or
  • 1 undiagnosed new problem with uncertain prognosis,or
  • 1 acute illness with system ic symptoms,or
  • 1 acute,complicated injury

“Condition Risk”

Presenting Problems – Moderate Risk

  • One or more chronic illnesses with mild exacerbation
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis
  • Acute illness with systemic symptoms …
  • Acute, complicated injury

The two lists provided above contain identical information, except for the highlighted section in yellow, which has been removed in the new 2023 MDM grid.


2023 Moderate MOM Column 2 Data Columns 2 and 3 DG’s Table of Risk
Management and Treatment Risk

Amount and/or Complexity of Data to Be Reviewed and Analyzed – Moderate MDM (e.g.,99284)

Moderate -Must meet the requirements of at least 1 out of 2 categories Category 1: Tests,documents,or independent historian(s)

  • Any combination of 3 from the following:

Review of prior external note(s) from each unique source

Review of the results of each unique test

Ordering of each unique test

Assessment requiring an independent historian(s); or

  • Category 2: Independent interpretation of tests,or
  • Category 3: Discussion of management or test interpretation
Management and Treatment Risk

Diagnostic Procedures Ordered and Management Options Selected – Moderate risk

  • Minor surgery with identified risk factors*
  • Elective major surgery*
  • Prescription drug management*
  • Physiologic stress and diagnostic testing
  • Cardiovascu lar imaging
  • Obtain fluids from body cavity
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation

* Same risk examples in 2023 CPT”moderaterisk level,social determinants newly added In CPT•.

The 2023 E/M guidelines combined columns 2 and 3 from the DG’s table of risk to illustrate management and treatment risk options and the potential data captured, including diagnostic studies, ordered tests, reviewed and interpreted results, discussions, and more.

A Reference Guide for Moderate MDM Examples in 2023 E/M Coding

Summing up, the NCOPA examples in Column 1 have been categorized and recorded as presenting problems. In Column 2, the data can be easily marked to indicate the relevant information captured during the encounter. Understanding the provider’s actions in addressing the patient’s problem(s) is crucial for determining the encounter’s risk level. This includes identifying the tests that were ordered and reviewed, documenting management discussions or interpretations, administering medications, and determining the final disposition of the patient. All of this data is thoroughly reviewed and analyzed to determine the next steps in managing the patient and finalizing their disposition, which is taken into account for MDM.

Condition Risk – Presenting Problem(s) Scenarios Management/Treatment MOM/Risk – Examples
  • Column 1 – Moderate NCOPA
  • One or more chronic illnesses with exacerbation,progression,or side effects of treatment

Mechanical complication gastrostomy or urinary catheter

Diabetes with high glucose or uncontrolled hypertension


  • Two or more stable,chronic illnesses

Diabetes and hypertension

One undiagnosed new problem with uncertain prognosis

Pregnant patient with any complaint

Patients who present via ambulance or CMS

Fever 100.SF or 38.0C

Chest pain

Abdominal pain,diarrhea, vomiting

Shortness of breath,edema

Potential foreign body any location

Weakness,dizziness,syncope, headache,neck pain

Systemic rash

  • Acute illness with systemic symptoms

Gastroenteritis type case

  • Acute,complicated injury
  • Column 2 – Moderate data,must meet at least 1 out of the 3 categories:
  • Category 1- Any combo of 3 from the following:

Review of prior external note(s) from each unique source

Review of the result(s) of each unique source

Ordering of each unique test

Assessment requiring an independent historian(s),or

  • Category 2 – Independent interpretation of tests;or
  • Category 3 – Discussion of management or test interpretation with external qualified source (not reported separately)

Moderate risk support items listed below may also meet individual moderate data category requirements above,i.e.,#3 below – Discussion of management – meets category 3 data. Each item supports moderate risk.

  1. Isolated EKG
  2. Evaluate, change, or replace tracheotomy,colostomy,gastrostomy,ileostomy, cystostomy tube(s),PICC Line,or Foley catheter
  3. Data (Category 3) – Discussion of management with other qualified healthcare provider
  4. Data (Category 1) – 1-3 X-rays ordered
  5. Data (Category 1) – One or greater lab studies ordered (excluding ABG, cardiac enzymes,troponin,cultures,lactate,etc.)
  6. Rx,oral,IM,IV meds (non-controlled),nebulizer meds,etc.

By examining the E/M MDM framework in this comparative perspective, it becomes evident that accurate documentation of an encounter and the ability to translate medical services into codes form the foundation of this system. Like any entity undergoing a new coding process, there is always scope for improvement and process refinement.

Accurate Coding Highlights

The coding process enables the flexible utilization of any two out of the three MDM elements in any sequence:

Nature of the problems to be resolved – What type of problem(s) is being presented?

Quantity/complexity of data – This is a straightforward checklist. Has it been completed or not? This aspect also influences the complexity of risk management and treatment. How much has been done to address the problem(s)?

Risk – All risks are associated with the presenting problem(s)/condition risk and how they are managed and treated – the risk involved in management and treatment.

Here are some rephrased highlights for provider documentation:

  • Record your assessment of external notes.
  • Note the orders and evaluations of distinct tests.
  • Document encounters with independent historians.
  • Capture independent interpretations of test results.
  • Include discussions with other Qualified Healthcare Professionals (QHP) regarding management or test interpretation.
  • Provide appropriate descriptive history and examination documentation.