About Bjorn Watsjold, MD

Emergency Medicine Chief Resident
Division of Emergency Medicine
University of Washington

ED Charting and Coding: Medical Decision Making (MDM)

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the coding elements within the medical decision making section have been revamped. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.

CMS Assessment of Medical Decision Making

The Centers for Medicare & Medicaid Services (CMS) evaluates MDM based upon the highest 2 of the following 3 elements:

  1. The number of diagnostic and management options to be considered
  2. The complexity of data analyzed, including charts, tests, and other sources (family, EMS)
  3. The risk of complications, morbidity, and mortality associated with the presenting problem(s) and subsequently with the procedures and management options for them.

These elements are presented qualitatively in the following table. See each section below for more quantitative scoring systems.


Let’s work through a sample case, and discuss how each section is documented and then scored.

Diagnostic and Management Options

Begin your MDM section with a summary statement of the patient encounter and list your differential diagnosis:

Ms. Example is a 25-year-old woman with a history of prior ectopic pregnancy who presents with acute RLQ pain concerning for ectopic pregnancy, PID, ovarian torsion, appendicitis, or other acute ovarian or abdominal pathology.

This case involves a new, acute problem with a broad differential including several high-risk diagnoses. These will apply to both the number and nature of problems and later to evaluation of risk.

Scoring the number of diagnostic and treatment options is accomplished in most places using the “Marshfield Clinic Scoring Tool,” which is not officially part of the E/M guidelines nor endorsed by CMS or the AMA. The tool tries to infer complexity from the nature of the problem and the effort it will take to address it. The following tables show the tool and the most common conversion from Marshfield “problem points” to the E/M guidelines element for number of diagnostic and management options.


The tool was developed for clinic appointments, but the American College of Emergency Physicians (ACEP) has recommendations to adapt it to the emergency department (ED) setting. The first distinction is new vs established problems. In the ED, most patients present with problems that are new to the examiner, so unless you are caring for a patient on a planned return visit, your cases will either be minor, self-limited problems (1 point for each problem) or new medical problems that require consideration, guidance for care, and often some kind of workup (3 or 4 points for each problem). Contrasted to the clinic setting, where testing is typically done between visits, in the ED we order, perform, and interpret most of our tests during the visit. So any new problem you can diagnose and manage by history and physical exam alone will score 3 points, and those requiring testing to guide diagnosis and management will score 4 points, as in the case of Ms. Example.

Ms. Example’s case should score 4 points for Extensive diagnostic and management options, because of her new abdominal pain requiring further imaging.

Data Review

The body of your MDM will describe how you work through your differential. Decisions based upon your history and exam require minimal additional information, but cases that require chart review, tests, and images are credited for increasing complexity.

To score your data review, you may use a table to calculate “data points” for the different kinds of testing, interpretation, and record review. In the table below, note that different kinds of testing score separately, and if you are providing your own read (even if you have a radiologist, cardiologist, or pathologist also on record) you get credit for that work. It’s important to include your interpretation of test results, both as part of your thought process and because your input counts.

As a side note, ECG interpretation must include ≥3 of 6 elements:

  1. Rate/rhythm
  2. Axis
  3. Intervals
  4. ST-segment changes
  5. Comparison to prior
  6. Summary of the patient’s clinical condition

You may also interpret the telemetry monitor recordings, which should include a mention of rate and rhythm.


I have ordered a CBC, BMP, and urinalysis with urine HCG. I will add a serum HCG if this is positive, in which case we will follow with US, or if negative I plan to proceed to CT scan of the abdomen. I also reviewed Ms. Example’s visit with Dr. Gyn 6 weeks ago, which showed that Ms. Example had negative UPT, gonorrhea, and chlamydia testing as well as a benign examination and unremarkable wet prep at that visit.

We will treat Ms. Example’s pain with IV morphine, and nausea with ondansetron.

On reevaluation, Ms. Example’s pain and nausea are significantly improved and she is resting comfortably, but she continues to have RLQ rebound tenderness. I have reviewed her laboratory results, which show an elevated WBC, normal hematocrit, and platelets. Her electrolytes and renal function are all normal. Her urinalysis shows no sign of infection, and urine HCG is negative, making ectopic unlikely. I have ordered a CT scan of the abdomen after discussing the above results with the patient.

I have reviewed the CT scan, which demonstrates a distended appendix with surrounding fat stranding that are concerning for appendicitis without perforation. I discussed with the radiologist the appearance of the right ovary and uterine tube, which are normal. I then consulted Dr. Jen Surgeon, who will admit the patient, and requested IV cefoxitin preoperatively. Ms. Example was informed of the CT scan results and consultation, and is amenable to the plan for admission and likely appendectomy. She will be kept NPO.

This gives us 1 for lab tests, 1 for radiology, 2 for your personal review of the CT scan, and 2 for your review and summation of old records (the OB visit), for a total of 6 data points. This indicates an extensive amount and complexity of data reviewed.


We can also address the level of risk involved for the presenting problem, testing, and treatment plan. The following table gives examples for risk, based upon the categories of presenting problems, testing required, and treatment plans. Important to note: the highest single item in any category determines the level of risk (CMS Evaluation and Management Services Guide, PDF).


The differential diagnosis for RLQ pain in a 25-year-old woman includes causes at each level of risk, and you should tailor both your differential and your workup appropriately to the presenting problem. Failure to account for higher-risk diagnoses, perform adequate testing, and appropriately escalate care are major areas of potential liability for EM providers. For Ms. Example, if you limited your workup to cystitis and ovarian cysts, this would be minimal to low risk. Considering pelvic inflammatory disease (PID) or other serious infection is moderate risk. Being appropriately concerned for appendicitis, peritonitis, and ovarian torsion reaches high risk. Non-invasive testing (labs and radiology) is considered low risk, but use of IV opioids to treat pain places the management level at high risk (drug therapy requiring monitoring).

Our sample case demonstrates High Complexity MDM based upon extensive diagnostic and management options, extensive data review and analysis, and high risk. It was quite thoroughly documented, but the scoring could be accounted for with just two items: a new problem requiring testing and pain treated with IV narcotics.


Work Smarter, Not Harder: Show Your Effort

The MDM is arguably the most important section of the patient’s record. There are many styles of documentation depending on your system, our example reflects the style we have adopted since using computer dictation, and many will be much shorter. Regardless, every MDM should include 3 core elements:

  1. Explain the complexity of the diagnostic and management options available to you by giving a brief summary of your patient’s presentation followed by your differential diagnosis, no matter how short.
  2. Describe and interpret the data that you obtained and reviewed. Be sure to use a phrase such as, “on my interpretation,” when you independently interpret radiographs or ECGs and briefly summarize prior visits that you reviewed.
  3. Be sure to mention the risk the patient is at due to their underlying pathology, the testing that is required to make a diagnosis, and the treatments that you administer or prescribe.

This example demonstrates the core elements of the MDM up to the point of admission for billing purposes, but leaves out the greater proportion of charts you will write: discharges. Documentation of discharge planning, return precautions, and unplanned discharges including those leaving against medical advice (AMA) and risk-minimizing measures will be covered in a future post.

By |2023-01-13T18:38:20-08:00Nov 16, 2016|Administrative|

ED Charting and Coding: Physical Exam (PE)


Editor’s Note (Jan 13, 2023):

The new AMA CPT 2023 Documentation Guidelines have been published and the prior physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

“What do I see, hear, and smell when I walk into the room?” While the oral boards challenge you to perform the physical exam in a certain way, the day to day examination of patients can vary dramatically. Centers for Medicare and Medicaid Services (CMS), however, has physical exam guidelines for billing that conform to neither the exam you learned as a medical student nor the one you’ve refined as a resident. These disparities between what you do and how you’re asked to document it can lead to charts that are frequently down-coded or at risk if audited. The following discussion tries to unravel some of these twisted regulations and will provide tips and tricks on how to improve your physical exam documentation for coding and billing.

Double Standards

“There are no straight backs, no symmetrical faces, many wry noses, and no even legs. We are a crooked and perverse generation.” – Sir William Osler

There are 2 very different standards used to bill CMS and/or insurance companies: the 1995 and 1997 CMS guidelines. Overall, 1995 is too vague, 1997 is too specific, and the responsibility to choose one or the other falls on your coding department.

The 1995 guidelines identify Body Areas and Organ Systems as a framework for documenting the physical exam, but do not say what to chart under either.

The 1997 guidelines define mandatory physical exam elements and called them Bullets. A comprehensive exam requires all bulleted items to be examined, and at least 2 per system to be documented. The full list of bullets is in the appendix at the end of this post. These guidelines also describe Single Organ System examinations, which focus on a primary organ system but require bullets from other systems. Don’t bother looking these up– in general, a comprehensive single organ system examination is more complicated to perform and document than a comprehensive multi-system exam.


* 1995 guidelines allow a combination of systems & body areas for PF, EPF, & Detailed exams.  ** 1997 multi-system exam requires specific bullets for each system.

Work Smarter, Not Harder: Resuscitating the Physical Exam

  • Develop a structured, comprehensive exam that you can perform on nearly any patient, and use the normal findings for this exam as your documentation template. If your department uses the 1997 guidelines, read through the bullets and pick 2 per system to include in your exam.
  • Your examination is part of your decision making. The chief complaint will indicate certain positive or negative findings to be documented.
  • With many EMRs, vital signs are usually automatically pulled into your note. In addition to reviewing all vitals as part of good patient care, include a statement in your documentation that the recorded vital signs were reviewed.

Sample template for normal comprehensive physical exam

Vital Signs: P / BP / RR / SpO2 / T [1]
I have reviewed the triage vital signs.

  1. Const: Well-nourished, Well-developed (WNWD), Young/Middle-Aged/Elderly Male/Female appearing stated age [2].
  2. Eyes: PERRL [1], no conjunctival injection [2], and symmetrical lids [3].
  3. ENMT: Atraumatic external nose and ears [1]. Moist MM [2].
    * Neck: Symmetric, trachea midline [1], No thyromegaly [2].
  4. CVS: +S1/S2, No murmurs or gallops [1]. Peripheral pulses 2+ and equal in all extremities [2].
  5. RESP: Unlabored respiratory effort [1]. Clear to auscultation bilaterally (CTAB) [2].
  6. GI: Nontender/Nondistended (NTND) [1], No hepatosplenomegaly (HSM) [2].
  7. MSK: Normocephalic/Atraumatic (NC/AT) [1], Extremities w/o deformity or ttp [2]. No cyanosis or clubbing [3]
  8. Skin: Warm, Dry [1]. No rashes or lesions [2].
  9. Neuro: CNs II-XII grossly intact [1]. Sensation grossly intact [2].
  10. Psych: Awake, Alert, & Oriented (AAO) x3 [1]. Appropriate mood and affect [2].

The 10 listed items are for both the 1995 and 1997 guidelines. The bracketed red numbers are the bullets for the 1997 guidelines. The * counts as a system/area in the 1997 guidelines.

Final Tips

  • Although technically acceptable under 1995 guidelines, avoid charting only “normal” or “abnormal” under a system, instead list specific abnormal or pertinent normal findings.
  • Find out which guidelines your coders use: the list of organ systems is mostly the same, but the 1997 rules require far more specific information.
  • From an ethical and medical legal perspective, if you document it, examine it! Tailor your smart phrases or macros to a list of normals you reliably perform on every patient, every time, and include placeholders for you to add patient-specific information.
  • If your department utilizes scribes (or incorporates medical student notes), take an extra second to review their documentation for completeness and accuracy.

Additional Reading

[su_spoiler title=”Appendix: Full list of Organ Systems and Body Areas” style=”fancy” icon=”caret”]

The following 12 Organ Systems are the same in the 1995 and 1997 Guidelines, with the 1997 Bullets listed for each:


  • Vital Signs (any 3 of the following): sitting or standing BP, supine BP, pulse rate & regularity, respiration, temperature, height, weight
  • General Appearance, e.g. development, nutrition, body habitus, deformities, attention to grooming


  • Conjunctiva & Lids
  • Pupils & Irises: size, symmetry, reaction to light, accommodation
  • Ophthalmologic examination of optics discs and posterior segments

Ears, Nose, Mouth, Throat (ENMT)

  • External inspection of ears and nose
  • External auditory canal & tympanic membranes
  • Assessment of hearing
  • Nasal mucosa, septum, & turbinates
  • Teeth, lips, & gums
  • Oropharynx: mucosa, salivary glands, hard/soft palate, tongue, tonsils, posterior pharynx

Cardiovascular (CVS)

  • Palpation: location (PMI), size, thrills
  • Auscultation: heart sounds & murmurs
  • Carotid arteries: pulses amplitude, bruits
  • Abdominal aorta: size, bruits
  • Femoral arteries: pulse amplitude, bruits
  • Pedal pulses: pulse amplitude
  • Extremities for edema and/or varicosities


  • Respiratory effort, intercostal retractions, accessory muscle use, diaphragmatic movement
  • Percussion of chest: dullness, flatness, hyperresonance
  • Palpation of chest: tactile fremitus
  • Auscultation of lungs: breath sounds, adventitious sounds, rubs

Gastrointestinal (GI)

  • Abdominal masses or tenderness
  • Liver & spleen
  • Presence or absence of hernia
  • Anus, perineum, rectum including sphincter tone, presence of hemorrhoids, rectal masses
  • Obtain stool for fecal occult blood test (FOBT)

Genitourinary (GU) – Male

  • Scrotal contents: hydrocele, spermatocele, tenderness of cord, testicular masses
  • Penis
  • Digital rectal exam (DRE) of prostate: size, symmetry, nodularity, tenderness

Genitourinary (GU) – Female

  • External genitalia and vagina: general appearance, discharge, lesions, pelvic support, cystocele, rectocele
  • Urethra: masses, tenderness, scarring
  • Bladder: fullness, masses, tenderness
  • Cervix: general appearance, lesions, discharge
  • Uterus: size, contour, position, mobility, tenderness, consistency, descent or support
  • Adnexa/parametria: masses, tenderness, organomegaly, nodularity

Musculoskeletal (MSK)

  • Gait & station
  • Inspection and/or palpation of digits and nails
  • Joints, bones, muscles: one or more of the following 6 areas: head/neck, spine/ribs/pelvis, right upper extremity (RUE), left upper extremity (LUE), right lower extremity (RLE), left lower extremity (LLE)
    • Inspection and/or palpation: deformities, asymmetry, crepitus, tenderness, masses, effusions
    • Range of motion (ROM) w/ notation of pain, crepitus, contracture
    • Stability w/ notation of dislocation/luxation, subluxation, or laxity
    • Muscle strength & tone (flaccid, cog wheel, spastic) w/ notation of atrophy or abnormal movements


  • Inspection of skin & subcutaneous tissues: rashes, lesions, ulcers
  • Palpation of skin & subcutaneous tissues: induration, nodules, tightening


  • Cranial nerves w/ notation of deficits
  • Deep tendon reflexes (DTRs) w/ notation of pathological reflexes (Babinski)
  • Examination of sensation: touch, pin, vibration, proprioception


  • Insight & judgement
  • Brief assessment of mental status
    • Orientation to time, place, & person
    • Recent & remote memory
    • Mood & affect: depression, anxiety, agitation


  • Palpation of nodes in 2 or more areas: neck, axillae, groin, other
1997 guidelines include two additional Organ Systems

  • Overall appearance, masses, symmetry, tracheal position, crepitus
  • Thyroid: enlargement, tenderness, masses

Chest (including breast and axillae)

  • Inspection of breasts: symmetry, nipple discharge
  • Palpation of breasts & axillae: masses/lumps, tenderness
Body Areas – used by the 1995 Guidelines
Head (including face)
Chest (including breast and axillae)
Genitalia, groin, buttocks
Back (including spine)
Extremity (each extremity counts as one body area)


By |2023-01-13T18:40:12-08:00Nov 9, 2016|Administrative|

ED Charting and Coding: Review of Systems

review of systems medical-chart-canstockphoto13003631-ros

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior Review of Systems section is no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

CMS Definition & Requirements

The ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced”. CMS recognizes the following organ systems* for ROS (1995 E/M Documentation Guidelines, PDF):

  1. Constitutional
  2. Eyes
  3. Ears, Nose, Mouth, Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

*Organ systems: A complete ROS must document systems, not regions of the body. This is an important distinction, e.g. Eyes and ENMT count separately, but Head and HEENT don’t count.

You can document 4 types of ROS, depending on how many of the possible 14 systems are reviewed:

E/M LevelROS TypeSystems Reviewed
II/IIIProblem Pertinent1

Work Smarter, Not Harder: Resuscitating ROS

How do you make this section useful?

  • Offload pertinent positives and negatives from the HPI into ROS.
  • Organize your history with HPI first, then ROS, and PFSH last (mimicking how CMS arranges the E/M guidelines) so you can document a concise HPI statement and move directly to ROS. This will make your charting efficient, yet effective and billable.
  • Use the ROS as a cognitive backstop. As a junior resident documenting ROS, I often realized I had forgotten certain history questions, did not have enough information to exclude an item on my differential, or that something the patient said did not fit with the rest of the picture, prompting me to re-evaluate my differential.
  • Have a quick, rehearsed set of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of breath? Vomiting or diarrhea? Painful urination? Rashes? Joint pain or swelling? Numbness or tingling? Changes in mood? Heat or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question set to your practice setting and specific patients.

Final Tips

  • One item– positive, negative, or normal– will suffice for each system.
  • If you use dot phrases or macros, have a 2-4 system ROS for most patients and a complete ROS for patients that will reach E/M level 5. Consider also having a separate pediatric ROS.
  • Always document at least 2 systems to prevent downcoding to an E/M level 2-3.
  • ROS can be obtained by ancillary staff or by patient questionnaire, as long as the physician reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: “I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient.” Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
  • A complete ROS can be a hybrid, listing pertinent positives and negatives by system, and then a notation indicating “All other systems are negative.”
  • Both caveats used in the introduction are valid examples per CMS. If you give a number of systems in your caveat, you must list that number of systems afterwards, so the second version is more straightforward.
By |2023-01-13T18:40:59-08:00Nov 2, 2016|Administrative|

ED Charting and Coding: History of Present Illness & Past Medical, Family, Social History

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior history and physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

medical chart history of present illnessRemember the “OPQRST” mnemonic? It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Not only can it guide your history taking, but charting these descriptors also ensures you can code at an appropriate level. The patient’s history is the first example of the balance between essential information and over-documentation. It should be comprehensive, yet be chief-complaint focused [1]. Below, we outline the components of a thorough and billable history.


The history includes 4 elements:

  1. Chief complaint (CC)
  2. History of present illness (HPI)
  3. Review of systems (ROS)
  4. Past medical, family, and social history (PFSH)

A chief complaint is required for all levels of charting. The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]:

  1. Problem Focused
  2. Expanded Problem Focused
  3. Detailed
  4. Comprehensive

The lowest common history level met by all elements determines the highest billable Evaluation and Management (E/M) level.

Remember “4-2-1” rule: 4 descriptors for HPI, 2 sections of PFSH, and 1 item per system for ROS guarantees a Comprehensive history.

E/M LevelHistory TypeHPIROSPFSH
IProblem Focused1-300
II/IIIExpanded Problem Focused1-310


If the HPI and ROS meet requirements for a Comprehensive History (E/M level 5) but the chart does not include any elements from the PFSH, this limits the history to Expanded Problem Focused. You can not bill higher than an E/M level 3.

Chief Complaint (CC)

Centers for Medicare & Medicaid Services definition:

“A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.”

A clearly stated CC may be documented in a physician’s note or a triage note [2].

History of Present Illness (HPI)

The HPI discusses details of the CC and provides a chronological story, usually with 3-4 of the following descriptors [1,2]:

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs/symptoms

A Brief HPI (E/M levels 1-3) requires 1-3 descriptors, while an Extended HPI (E/M levels 4-5) requires ≥4 descriptors [2,3]. Note that E/M level 4-5 charts can still be concise.


The patient is a 34 y/o M presenting with chest pain (chief complaint) that is substernal (location), starting an hour prior to arrival (duration) while mowing the lawn (context), feels “like a pressure” (quality) that is intermittent (timing) and severe (severity), with associated nausea and diaphoresis (associated signs/symptoms).

This qualifies for Comprehensive, E/M Level 5 with 8 HPI descriptors.

Review of Systems (ROS)

Keep your eye out for our next post, where we will dive into the complexities of ROS.

Past Medical, Family, and Social History (PFSH)

Past Medical History (PMH) includes chronic diseases, past illnesses/injuries, and operations/treatments. Family History (FH) is a review of medical events including hereditary and non-hereditary disease. Social History (SH) is a review of pertinent age-appropriate current and past risks factors such as alcohol/tobacco/drug use, sexual history, employment, and education. You must document one specific item for a Detailed history (E/M level 4) and at least one item each in two areas for a Comprehensive history (E/M level 5) [2,3].

Example for Detailed History, E/M level 4

  • PMH: Hypertension, hyperlipidemia, diabetes mellitus. [Detailed, E/M level 4]

Example for Comprehensive History, E/M level 5

  • PMH:Hypertension, hyperlipidemia, diabetes mellitus
  • SH: smokes cigarettes 1 ppd

A common misconception is that listing two past medical problems (e.g. hypertension, diabetes) are still all counted as two items. They are instead all under one item (PMH). You still need to list an item from either the SH or FH to be eligible for E/M level 5. Thus this would drop the coding from a potential E/M level 5 down to a level 4.

The PMFH recorded by ancillary staff (e.g. tobacco use recorded at triage as part of the SH) counts as long as it is included in your documentation with a statement of review and confirmation [1]. Example: “Past medical, family, and social histories reviewed and verified by me.”

Additional Tips

  1. CC, ROS, and PFSH may be recorded by ancillary staff or via patient questionnaire, but you must document that you have confirmed this information with the patient [2,3].
  2. What if a patient is unconscious, intubated, or refuses to give a history? If a patient’s condition or circumstance limits acquisition of any history component, add a qualifier describing the limitation, e.g. cannot obtain due to encephalopathy, dementia, intubation, etc. This qualifier applies to all elements of history: HPI, ROS, and PFSH [2,3]
  3. Did you play detective and obtain a history through other sources? Get credit! As an alternative to the extended HPI (E/M level 5 HPI), you can discuss the status of at least 3 chronic or inactive conditions [1,2]

Example: Patient sent from nursing home for altered mental status. He is nonverbal at baseline, but per nursing staff and transfer records, his (1) urinary retention has been stable with Foley in place, he (2) has not missed any seizure medications, and (3) the staff has been controlling his blood glucose well.

A statement describing how and what additional history was obtained will add to the complexity of data review in your medical decision making (MDM), which will be detailed in a later post). The statement “Additional history obtained by family/extended care facility staff” without elaboration will not count [2].

Work Smarter, Not Harder

The elements above describe the minimum data for each level. It is important to include additional data as appropriate and to avoid potential down-coding; however, be cognizant of wasting time or space recording historical information which neither contributes to your thought process nor billing. Some items are relevant to many aspects of care: diabetes in the family, bleeding and clotting diatheses, smoking history, and illicit drug use are both PFSH and risk factors. A patient’s living situation is relevant for disposition. Do not include “not relevant” or “non-contributory” history as it does not contribute to billable documentation.

See the PV Card on ED Charting and Coding


  1. Guth T, Morrissey T. Medical Documentation and ED Charting. CDEM Curriculum. 2015. Accessed 30, 2016.
  2. 1997 Documentation Guidelines for Evaluation and Management Services (PDF). Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.
  3. Evaluation and Management Services Guidelines (PDF). Department of Health & Human Services: Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.

(c) Can Stock Photo

By |2023-01-13T18:35:53-08:00Sep 5, 2016|Administrative|

PV Card: Introduction to ED Charting and Coding

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have completely revamped how the billing and coding for Emergency Department charts is done. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

ED charting and coding computer-charting-TEXT-canstockphoto17902161What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding [1–3] and resident charts are more often down-coded due to documentation failures than those of attendings and PAs [4]. Thankfully, resident education in charting has improved over the past 15 years [5], and a little learning goes a long way to improve confidence [6] and competence [7].

In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.

What is a CPT code? What is an E/M level?

In order to uniformly bill for services provided, the American Medical Association (AMA) maintains a list of Current Procedure Terminology (CPT) codes. When you provide medical services to a patient, the chart is billed using a CPT code based on Evaluation & Management (E/M) levels 1-5 [8]. Most ED visits are billed as E/M levels 3-5. In order to objectively categorize a chart, Centers for Medicare & Medicaid Services (CMS) created a coding system to assign an E/M level.

What is the difference between a lower and higher E/M level chart?

Three essential elements determine the E/M level: history, physical exam, and medical decision making (MDM). Each of these components is evaluated by a set of guidelines and categorized by the documented elements of the history/physical exam and complexity of MDM. After evaluating each essential element separately, all three are considered in choosing an E/M level and CPT code that is billed. The complexity of your MDM should ultimately determine your E/M level, but under-charting in another area will limit you from billing an appropriately high E/M level.

On your next shift, take a second to review your charts. Could one additional word in the history of present illness (HPI) bump a level 3 up to a level 4? Did you mention your chart biopsy, even if it was just skimming the most recent discharge summary or yesterday’s note? The following PV card outlines the minimum elements needed from all 3 areas required to code specific E/M levels, and shows that a single word or phrase may be the difference in clarifying a higher level of care provided.

Keep an eye out for our follow-up posts. We’ll focus on individual sections of the chart (history, physical examination, MDM), specific diagnoses and special situations that require extra care when documenting.

Happy charting!


  1. Howell J, Chisholm C, Clark A, Spillane L. Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey. Acad Emerg Med. 2000;7(10):1135-1138. [PubMed]
  2. Pines J, Braithwaite S. Documentation and coding education in emergency medicine residency programs: a national survey of residents and program directors. Cal J Emerg Med. 2004;5(1):3-8. [PubMed]
  3. Dawson B, Carter K, Brewer K, Lawson L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11(2):116-119. [PubMed]
  4. Ardolic B, Weizberg M, Cambria B, et al. 362: Documentation and Coding Skills: Is There Adequate training in Emergency Medicine Residency? Ann Emerg Med. 2006;48(4):108.
  5. Heiner J, Dunbar J, Harrison T, Kang C. 426: Current Emergency Medicine Residency Education of Documentation, Coding, and Reimbursement: Fitting the Bill? Ann Emerg Med. 2010;56(3):137-138.
  6. Takacs M, Stilley J. 169: Billing and Coding Shift for Emergency Medicine Residents: A Win-Win-Win Proposition. Ann Emerg Med. 2015;66(4):60.
  7. Carter K, Dawson B, Brewer K, Lawson L. RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment. Acad Emerg Med. 2009;16(5):423-428.
  8. Evaluation and Management Services Guidelines. Dept of Health & Human Services: Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Published August 2015. Accessed July 24, 2016.
By |2023-01-13T18:42:49-08:00Aug 15, 2016|Administrative, ALiEM Cards|
Go to Top