2023 Emergency Medicine Coding Guide

a. High: ≥1 chronic illnesses with severe exacerbation, progression, or side effects of treatment

b. High: 1 acute or chronic illness or injury that poses a threat to life or bodily function

a. May require admission/aggressive treatment and care escalation

b. Threat to life/body function without treatment

c. Moderate: ≥1 chronic illnesses with exacerbation, progression, or side effects of treatment

d: Moderate: 2 stable, chronic illnesses

e. Moderate: 1 undiagnosed new problem with uncertain prognosis

f. Moderate: 1 acute illness with systemic symptoms

g. Moderate: 1 acute, complicated injury

c. Chronic problem that is worse than baseline

d. Chronic illnesses are at baseline

e. New, serious undiagnosed problem

f. Serious systemic symptoms associated with acute illness

g. Extensive injury, impacting multiple body systems, higher risk of morbidity with multiple treatment options

h. Low: ≥2 self-limited/ minor problems

i. Low: 1 stable, chronic illness

j. Low: ≥1 acute, uncomplicated illness or injury

k. Low: 1 stable, acute illness

l. Low: ≥1 acute, uncomplicated illness or injury requiring inpatient or obs care

h. ≥2 self-limited problems

i. Chronic illness at baseline

j. Limited injury, low risk of morbidity, little to no mortality risk

k. Newer illness or diagnosis that is stable

l. Minor, new problem or injury that requires hospital care

• Drug therapy requiring intensive monitoring for toxicity

• Decision regarding elective major surgery with identified patient or procedure risk factors

• Decision regarding emergency major surgery

• Decision regarding hospitalization or escalation of hospital-level care

• Decision not to resuscitate or to de-escalate care because of poor prognosis

• Parenteral controlled substances

• Prescription drug management

• Decision regarding minor surgery with identified patient or procedure risk factors

• Decision regarding elective major surgery without identified patient or procedure risk factors

• Diagnosis or treatment significantly limited by social determinants of health

Must meet at least 1 of 2 categories:

Any combination of 2 from the following:

• Ordering of each unique test

• Review of the result(s) of each unique test

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

Category 2: Assessment requiring an independent historian

Must meet at least 1 of 3 categories:

Any combination of 3 from the following:

• Ordering of each unique test

• Review of the result(s) of each unique test

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

• Assessment requiring an independent historian

Must meet at least 2 of 3 categories:

Any combination of 3 from the following:

• Ordering of each unique test

• Review of the result(s) of each unique test

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

• Assessment requiring an independent historian