Aligning Emergency Medicine with 2023 CPT Guidelines: Sayvant’s Approach

The AMA’s 2023 CPT guideline updates are transforming emergency medicine documentation. Medical Decision Making (MDM) now takes center stage, moving history and physical exam metrics to the background when selecting ED E/M codes.

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Crafting the Ideal Emergency Medicine Note in 2023

The AMA’s overhaul of E/M services shifts the focus from history and physical exams to MDM. Here are the top three components every emergency physician should prioritize:

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1. Medical Decision Making (MDM) as the Core

MDM is now the primary factor determining E/M service levels in the ED. While history and physical exams remain important, they no longer directly influence code selection. Instead, MDM captures the clinical judgment involved in managing patient care, such as deciding to order an EKG or CT angiogram for a patient with acute chest pain. This documentation should reflect your thought process, from diagnosis to treatment, considering both complexity and risks.

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2. Number and Complexity of Problems Addressed

The new guidelines also emphasize the number and complexity of problems handled. If you're managing a patient with multiple comorbidities, such as diabetes and hypertension, along with an acute issue like pneumonia, your documentation must reflect how these conditions interact and influence your treatment plan.

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3. Risk of Complications and/or Morbidity or Mortality

Risk assessment—covering complications, morbidity, or mortality—plays a pivotal role in MDM. This includes not only immediate clinical risks but also social factors like homelessness that may affect outcomes. Whether you opt for further testing or decide to observe, these decisions add to the complexity of care and should be well-documented.

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How Sayvant Aligns with 2023 CPT Guidelines

Sayvant is fully equipped to ensure your notes align with the 2023 CPT changes, supporting emergency physicians in delivering excellent care and accurate documentation.

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• Medical Decision Making (MDM)
  Once you provide a diagnosis and disposition, Sayvant generates a detailed MDM note that captures the nuances of your clinical judgment. Drawing from peer-reviewed guidelines, Sayvant ensures your documentation reflects the real work performed in the ER.
• Number and Complexity of Problems Addressed
  Sayvant listens to your interactions with patients, interprets your conversations, and seamlessly integrates complex cases into the documentation. We ensure that every detail of your clinical assessment is captured in real time.
• Risk of Complications and/or Morbidity or Mortality
  Sayvant’s ambient listening technology goes beyond documenting clinical risks, incorporating social factors that may impact patient outcomes to offer a more holistic view of the patient’s condition.

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At Sayvant, we’re dedicated to helping emergency physicians maintain documentation excellence while focusing on what matters most—patient care.

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