Changes to the 2023 Evaluation & Management (E/M) Definitions for Acute Conditions

Changes to the 2023 E/M Definitions for the Acute Problems 

If you report Evaluation and Management (E/M) services, you are likely well aware of the major changes that occurred in 2021, which facilitated selecting the level of service based on scoring medical decision making (MDM) or time. Changes at that time were only made to the codes in the E/M category of Office or Other Outpatient E/M services (99202-99215), but in 2023, the remaining E/M categories are undergoing very similar changes. 

One major change in 2021, was the addition of definitions to clarify specific MDM terminology; however, due to confusion surrounding some of these definitions, an additional update was made in April of 2021 to provide further clarity. Now, with the changes to the other E/M categories, new terminology is being introduced and thus the definitions have undergone additional changes. Those definitions specific to the first element of MDM, the "Number and Complexity of Problems Addressed," are the definitions this article will be addressing. 

In 2021, there were eight levels of complexity associated with diagnoses, but in 2023, two additional diagnosis complexity definitions have been added. These two correlate with the changes to E/M services in the inpatient facility setting. For ease of understanding and comparison, we have grouped acute definitions together, followed by the chronic definitions. 

Removal of the prior 2021 examples for each condition definition is a common theme in the 2023 E/M guideline changes. 

Definition Changes to Minimal, Self-Limited, or Minor Problems

The two levels of complexity related to a minor condition, the least severe of all conditions include: Minimal Problem and Self-Limited or Minor Problem, which we will further review here.

Minimal Problem: For 2023, only the definition of minimal problem was changed, and only to add code 99281, which used to be the lowest level of complexity for Emergency Department (ED) E/M services, within the range of 99281-99285. 

In my last article “Significant Changes to Emergency Department (ED) Reporting Coming in 2023” we talked about how, beginning in 2023, the lowest level of ED E/M services, code 99281, will no longer be a provider code but instead, similar to 99211, is reported in the Office and Other Outpatient setting. Nursing staff will begin to report this code for specific nursing services performed under the supervision of an ED physician. Therefore, the only change the definition for "Minimal Problem," is the addition of 99281 linked to this level of complexity.

Self-Limited or Minor Problem

No changes were made to Self-Limited or Minor Problem for 2023.

Definition Changes to Acute Problems

While the codebook definitions do not define an acute condition as far as duration is concerned (e.g., less than three months), it does describe it as, “a recent or short-term problem.” Keeping that in mind, being able to differentiate acute from chronic is not a coder’s job, that is the job of the provider but unfortunately, there are many times when providers do not clarify whether a condition is acute or chronic.

For example, rotator cuff tears are usually due to an injury in younger people but in older people are often due to degeneration of the tendon fibers with age. Unless a tear, resulting from an injury is severe, the general first line of treatment is conservative measures, including anti-inflammatories and physical therapy. If conservative therapy fails, the provider may recommend surgical repair. 

The ICD-10-CM codes for reporting a traumatic rotator cuff tear (sprain) are selected from Chapter 19: Injury, poisoning, and certain other consequence of external causes (S00-T88). However, those rotator cuff tears that are not specified as traumatic, are reported with codes from Chapter 13: Diseases of the musculoskeletal system and connective tissues. There is no difference when it comes to selecting the right codes; the providers need to be trained to document for clarity. Additionally, when reporting surgical repair of a rotator cuff tear, the procedure codes to be reported are either 23410, for an acute tear, or 23412, for a chronic tear. 

Needless to say, there are a lot of queries submitted for clarification regarding these diagnosis codes to clarify whether the patient has an acute tear versus a chronic one. 

So let’s look at a few of these definition changes for 2023 related to acute conditions: 

Acute, uncomplicated illness or injury

“A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.”

In 2023, the only change to this definition is the removal of the statement, "Examples may include cystitis, allergic rhinitis, or a simple sprain.” It is important to note that although these examples have been removed, they still provide a good reminder of what the AMA considered to resemble an acute uncomplicated illness or injury. 

New Hospital-Related Definition

To correlate with the changes to E/M facility services, two new diagnosis complexity definitions were added, as follows: 

"Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in the hospital inpatient/observation setting."

This definition describes a problem that has a recent onset requiring the attention of a medical professional; however, there is a very low risk of disease progression (morbidity) or death without treatment, but with treatment the patient should recovery completely. Treatment for this type of condition needs to be provided in a hospital setting, such as observation or inpatient admission. A few conditions that come to mind include a urinary tract infection (UTI), that requires culture for adequate antibiotic coverage; a kidney stone, pneumonia, requiring respiratory treatments and intravenous (IV) antibiotics; or even a traumatic fracture, requiring surgery to set the bone before heading home. 

The second definition added in 2023 is for a stable, acute illness, defined as follows: 

“Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.”

The next diagnosis complexity definition is one we are all familiar with but which now, as of 2023, has an added clarification: 

The next diagnosis complexity definition is one we are all familiar with from 2021, but for 2023, has an added sentence for additional clarity. 

Undiagnosed new problem with uncertain prognosis

"A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment."

Again, here the 2023 changes to this definition removed the statement, "An example may be a lump in the breast." Again, just because the AMA removed the example of a breast lump provided in 2021 with this diagnosis, does not mean it would be wrong to report this diagnosis complexity if the patient did in fact have a lump in the breast. 

An undiagnosed new problem indicates the documentation will likely contain a differential diagnosis (a possible, probable, or suspected) diagnosis that has not yet been confirmed. In circumstances such as these, it is best to refer to the ICD-10-CM coding guidelines for the place of service where the service is being performed for instructions on what to report for a diagnosis, as there are rules based on place of service, such as inpatient discharge service, observation, or in the office or other outpatient setting.

Example: John is a 12-year-old male with complaints of rapid and irregular heartbeat with syncope but no known cause. Differential diagnosis may be mitral valve prolapse, Wolf-Parkinson-White, or redundant cardiovascular circuitry. We will get the patient set up for a 24-hour Holter monitor and echocardiogram this week. He should avoid any strenuous activity and a physician's note has been provided to his mother to present to the school to excuse him from gym. John voices understanding that if it turns out to that he has WPW and he continues to exercise, this could be very dangerous. We will know more after additional testing.

In this scenario, since the provider did not document a confirmed diagnosis, the coders should report the patient's symptoms. However, once a confirmed diagnosis has been documented, the coders would no longer report the symptoms and instead, report only the diagnosis that explains the patients symptoms. The unknown diagnosis raises the level of complexity to moderate, as we are uncertain as to the outcome but expect that it may turn out to be one that carries a higher risk of morbidity without treatment. A breast lump may represent breast cancer, rapid and irregular heartbeats may result in tachycardia or uncontrolled atrial fibrillation, and symptoms and physical examination are insufficient for diagnosing the condition.

Acute illness with systemic symptoms

"An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system."

Systemic symptoms means affecting multiple organ systems in the body, but the AMA goes on to clarify this also refers to symptoms affecting a single organ system but not those that would be general symptoms of a minor illness, body aches, or fatigue that is already associated with a minor illness. 

An example of an acute illness with general symptoms of a minor illness that does not quality here, could be a patient who was seen in the ED over the weekend and prescribed antibiotics for otitis media (ear infection). Today, less than 24 hours later, she presents with complaints of fever, ear pain, and irritability. The provider explained that the symptoms are normal but would subside after 24-36 hours on antibiotics but in the meantime she can take over-the-counter Tylenol or ibuprofen for her symptoms. 

An example of an acute illness with systemic symptoms that could pose a high risk of morbidity without treatment, could include a patient who presents with pain, fever, and an open leg wound that appears to be infected. This would require evaluation, examination, treatment of symptoms, and treatment of the leg wound, that if left untreated could result in a systemic infection of the blood, or sepsis.

Acute, complicated injury

"An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity."

To identify a complicated injury, providers must become adept at identifying what makes the injury complicated. For example a fracture may be compounded with rocks and debris in the open wound requiring significant debridement. Descriptive words are helpful in identifying complexities of an injury that require additional work than would be considered normal for an injury without complications. 

Acute or chronic illness or injury that poses a threat to life or bodily function: 

"An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity."

Again, a provider who is adept at documenting the complicating factors of an illness or injury makes it easier for coders to identify a correct level of complexity. A great way for providers to document, however, is to have them assess what they feel the level of complexity is for the patient's illness/injury, and then document to meet that level of complexity. If, while documenting, they realize the complexity is a bit lower, it is always easy to report a lower level of service. However, without these important details, it will be difficult support a higher level of complexity. 

So to recap, these are the variations of acute illnesses, conditions, or injuries for which differing levels of complexity have been assigned: 

• Minimal or self-limited/minor problem (straightforward)
• Stable, acute illness (new) (low risk)
• Acute (uncomplicated) illness/injury (low risk)
• Acute (uncomplicated) illness/injury requires hospitalization/observation for treatment (low risk)
• Undiagnosed new problem (uncertain prognosis) but likely to result in high risk of morbidity without treatment (moderate risk)
• Acute illness with systemic symptoms (not general symptoms) (moderate risk)
• Acute (complicated) injury (moderate risk)
• Acute (or chronic) illness/injury that poses a threat to the patient's life or bodily function (high risk)

For further exploration, check out this article on the changes to the 2023 E/M Diagnosis Definitions for the Chronic Problems. Click Here.

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