There’s big news in the world of medical billing. CMS has released a proposed rule that would completely eliminate the use of documented history and exams for determining the level of service for care provided in the emergency department. In other words, although clinicians must document a “medically appropriate” physical and exam, the CPT code assigned to the services provided will only be based on the complexity of the medical decision making performed.

CMS’ release of this new rule comes after months of debate about its many facets. When these changes were first being discussed, there was considerable disagreement about what would and would not be considered in determining code level — for example, using time spent at the patient’s bedside was originally considered as a component of the complexity calculation for each level of service. Thankfully, this idea was omitted from calculations for emergency medicine, which differs from other specialties. In the end, the rule laid out three factors of MDM that are to be included in the calculation of care complexity.

The first factor is the number and complexity of problems being addressed. In this factor, more problems means more complexity; if diabetes and bacterial infection are both being treated at the same time, for example, the “complexity” of the services would be higher than if just one or the other were being addressed.

The second factor is the amount and complexity of data. As every patient’s needs are highly specific, this factor takes into account time and effort needed to do things like review records, interpret tests, and discuss further treatment with relevant individuals.

Lastly, the third factor used to calculate care complexity is determining the risk of the care plan. This is done by assessing use of prescription medications, examining the social determinants of the patient’s current health affecting the care plan, and determining the need for hospitalization.

In addition to outlining a completely new process for assigning the level of care for services, this proposed rule by CMS also is a landmark event, in that medical billing guidelines from CPT (the overseeing committee from the AMA) and CMS will be aligned for the first time in 20 years in terms of level of service coding. This will decrease opportunities for disagreement between providers and payors on the appropriate CPT code for each service, thus hopefully reducing time and effort from both parties on claim denials and downcoding.

While these proposals are exciting, the specifics of this rule still need to be confirmed in the final rule this Fall before they are implemented in January of 2023. For more detail about the proposed rule, see the CMS website. As of right now, it is unclear whether this rule will be adopted as-is, or if there are changes that will be made in the final rule that will impact day-to-day emergency department operations. We will update you on other aspects of this proposed rule as well as the final rule as more information becomes available.