Trimming the Fat of Note Bloat: 2023 Documentation Guidelines Broken Down with Jason Adler The SimKit Podcast

In 2023 we saw a huge change in the way our charts are billed. Understanding the changes to these documentation guidelines not only affects how much money we/our hospital get for the work that we do, but also has the potential to influence the care provided by others and the funding of healthcare system in the future. So it’s a big deal. We are joined by Dr. Jason Adler, Clinical Assistant Professor at the University of Maryland and VP of Acute Care Solutions at Logix Health, to talk about “Trimming the Fat of Note Bloat.”


Jason Hine: Hello, everybody, and welcome back to Simkit. We’re gonna be talking about the changes that we have seen all have seen and been a part of since the start of the year, documentation changes in 2023. I am joined by Dr. Jason Adler. Clinical Assistant Professor at the University of Maryland, and the VP of Acute Care Solutions for logics health. Now, I got to know Jason through, AAEM, and was really blown away by the reviews in his talk of AM 2022. “Trimming the fat of Note Bloat, 2023 documentation guidelines you Need to Know.” Jason, congratulations on successfully creating an engaging talk on what many of us might sort of find to be the bane of our existence in the emergency department, right? We have to document all the cool stuff we get to do on a day-to-day basis diagnosing people and saving lives. So Jason Dr. Adler, thank you for joining us today.

Jason D. Adler: Pleasure to be here Jason.

Jason Hine: Now, what do we as ED clinicians need to know about the documentation changes that came down the pike this year 2023?

Jason D. Adler: I’m really excited to be here Jason and long time listener, first time caller. 

Jason Hine: Fantastic.

Jason D. Adler: It may be helpful to pull back the lens for a minute and talk about how we got here. 1995. That was the first time that we had a structured set of documentation guidelines that converted the cognitive work that we perform in our ads over to payments. And we lived with this for 28 years. Now those guidelines were converted to a brand new set of guidelines. The old ones were retired. New ones were released in January 1 to 75 days ago. January 1 2023. The two most important points about these two guidelines involving the history and exam are no longer scored and code selection that 99281 to 285 representing approximately 83% of all our RVUs, in emergency medicine- The code selection is all about the medical decision making.

Jason Hine: Okay, that’s quite a long time to be going without any updates, right? We get software updates for our phones at a much higher clip than the updates that come for our medical charting. Do you have any sense of why there was such a delay? Is this a broad strokes, big sweeping change? It sounds like it might be.

Jason D. Adler: It’s fairly significant and we have gone for 28 years, there were some updates and some errata and modifications over that period of time, but, as we transitioned into 2023, there has been the last several years, a significant emphasis by our administrations to have a heightened sensitivity surrounding, Note Bloat, and Click Fatigue, and Wellness, and Resilience. And all of the things that we on the front line and emergency medicine. And in fact, all healthcare providers are involved with to reduce that documentation burden. And that may have been a driver in this new update.

Jason Hine: Okay, that’s good to hear. That makes me a little bit optimistic that some of this has our best interest in mind. So I noticed, you know, one of the most notable things that come out of this, in my mind, is that sort of devaluation of the history and physical exam I mean, I like all this, we spent much of our time getting the history from the patient, significant other, EMS and trying to keep alive, that dying art of physical examination. Why are we now saying that this is not important?

Jason D. Adler: It’s a great question and I’m not sure if the guidelines are going in completely in that direction. What they do say is that the history in the exam, no longer scored, as it relates to code assignment. The guidelines reference a medically appropriate history and examine. What we are seeing is a very strong physician voice in these guidelines. These guidelines were created by the American Medical Association CPT that physician voice is strong and present. In fact, to quote that guidelines specifically, there is a reference to “the main purpose of documentation is to support care of the patient by current and future health care teams.” The guidelines ask for a medically appropriate, history and exam. And if we look at the evolution of our documentation, way before you or I got into medicine, they were paper records, evolving over to T sheets and the electronic health record came into play, the notes got bigger, we kind of touched a little bit on note bloat, and then Click Fatigue. We send them more and more time at the EMR, and that may not have been a good thing. It’s not that the history and exam are devalued, it maybe that other areas of the chart, specifically the medical decision making are more valuable and the cognitive work that we are doing is what are valued and specifically relates to the code assignment of the work that we do.

Jason Hine: Okay, again that sounds like a promising thing to me. I mean, trimming the fat, trying to get rid of some of that stuff, sounds like a nice step in the right direction.

Jason D. Adler: Absolutely. And there are certainly clinical and quality considerations that you would take into account when documenting your history and exam. You mentioned, your fondness of doing a thorough exam on a patient. And you talk about getting a good history related to the nature of the presenting problem and why the patient came to the department. There’s significant value there especially for risk for quality for communicating a medical record to the next clinician that reads.

Jason Hine: Yeah.

Jason D. Adler: It, it’s not just about the coding, The history and exam is more focused on quality risk. And then the quoting specifically is related to the medical decision making

Jason Hine: Right. Right. And I want to rehighlight the idea that they’re trying to make our notes or help us craft notes, that are valuable to our future selves. And our colleagues that it’s a means of communication Certainly with the patient. You know, that’s almost a separate topic,, but to make a note that’s digestible and, you know, fat trimmed for the next clinician who has to care for the patient.

Jason D. Adler: It’s an ambitious goal Jason. And last year on May 23rd. Our Surgeon General. Dr. Vivek Murthy referenced a goal to reduce the documentation burden by 75%. by the year 2025. It appears as though, even though we’re on the third administration focusing on patience over paperwork, there’s a heightened sensitivity towards reducing that documentation burden, and you see it in these guidelines, in the reduction, in the requirements related to the history and the exam section.

Jason Hine: Fantastic. But it does sound like now my you know “all other review systems asked a negative” lie, that we’ve probably been putting out there. It’s, you know, it’s a thing of the past. I guess, you know, I say that half jokingly, but the truth of the matter is that the HPI, the review systems, the physical exam. You’re saying that it’s not that these are unimportant clinically, but it informs your differential, your workup. The things you’re gonna be doing to help the patient succeed at home, but we can’t really count quote unquote on these to raise or lower the billing level of our encounter. So, Jason, what then really is important for that billing element.

Jason D. Adler: With these new guidelines, it really is about the medical decision making. That is the beginning and the end of the story. Now, there’s some components related to the MDM that will get into in a moment that may involve some history sections, but that’s scored within the medical decision making section of the grid and the chart.

Jason Hine: All right. I like that. That’s a clean answer MDM. You can almost answer that in In, you can almost answer that question in three letters. So the meat of the matter is, in the medical decision, making How then is the MDM quote unquote scored.

Jason D. Adler:  Yeah, we’ll switch over for a moment into the coder’s lens and talk about this grid. It’s got a purple at the top, you’ve got a full page, three columns. They’re all these words that are at a six points. There are all these words at a six point font and the three columns involved. Complexity data and then risk. And when the encounter is scored, each area of that complexity in data, and risk are in are scored together. And with the top two of the three determines the final code selection. Now, that’s from the coders lens and neither of us or coders. So, let’s make it clinically meaningful and we’ll talk about complexity first. From a clinical standpoint, complexity. How does that get scored? Well, it comes through the differential and your comorbidities. the differential, we all know that in our current modern practice of medicine that we occasionally will see these dot phrases that include 30 different diagnoses for a certain condition and I think most in the risk management community and the quality, that’s not really the best way to go about documenting your chart. And at the same time, not documenting a differential, maybe potentially have some issues. So, the middle ground approach to describe a differential as it relates to the complexity of the visit is to focus on a targeted differential.  For example, if a patient comes in who was maybe found down, you get information by EMS, suspect intoxication, your workup may include a CT and in your documentation if you wrote an act of tense “CT order to evaluate for ICH” you’re declaring your differential in the context of your workup. Same thing with chest, pain, patients PEC negative, not consistent with PE. We’ll check enzymes for ACS. You’re describing your differential in the context of what you’re actively working up for your patient and that’s very far away from a dot phrase and it’s also very far away from writing, nothing at all. And that all bleeds in to the complexity of the evaluation of the care that you’re providing for your patient. And then we have comorbidities. Comorbidities support your risk stratification. We know that. You look at the Heart Score has comorbidities as part of the scoring scale to stratify that patient. Comorbodities will elevate your differential and it’ll demonstrate the cognitive intensity you’re performing to evaluate the patient. A patient who comes in with a cellulitis, maybe young will have a certain work-up performed, and at the same patient has peripheral vascular disease potentially diabetes. You may have a different approach to that patient so including the differential and then subsequently the comorbidities in your documentation will demonstrate the complexity of the work that you’re doing and will allow the coder to capture that work.

Jason Hine: Fantastic. First, I want to go back slightly and if I could stand up and start applauding, I would no one would see it. You might hear me. But I have always had those dot phrases that pull out every possible cause of chest pain as just why, why are we doing that? Why are the learners incorporating that into their chart? And this is personally very validating so I love that the idea of no MDM obviously bad,… The idea of an MDM that auto-populates really you’re saying that what we want our empty DM to be is to be our mental processing. Our incorporation of multiple data points. Both from the reason, the person is presenting the comorbidities, as you mentioned the differential, in the way that we work through it. If you just take that into dot chest pain, what you’re kind of undoing that entire thought process. And if you look at those, you find that most of the time, it’s not really part of the conversation, right? Borehaves wasn’t really considered because the person never had vomiting, there’s no concern in that regard at all. So why include that in your differential consideration for chest pain artificially? It’s almost the newer version of Note Bloat if we’re stuck in that if we’re in the MDM realm, that would be adding things that you’re not actually mentally processing through just to Artificially almost increase the complexity of the cases. Is that a fair statement about that topic?

Jason D. Adler: It’s so well, said, Jason and what what you’re articulating is by being very precise, with the words that you use that’s focused on the patient that you’re caring for in the moment that will support the coding for the chart in the end. And you don’t necessarily need to have all this bloat with dot phrases and all these words for conditions that could potentially expose you to risk and do other things that can create some problems here or there. These guidelines will reward you for having a targeted differential, acknowledging the comorbidities that affect that differential and affect the management of your patient. And then you would get credited on the complexity section in the end. So it really seems to be an opportunity to truncate our notes, be more precise, and that will also create more accurate descriptions for the coder to identify and code your chart.

Jason Hine: Amen to that brother. I love that idea and that makes me actually more excited. You know, I we’ve been living with these for a little while and I’m getting used to how I need to think and put my mind on paper or digital paper. But man, that really is, it’s a breath of fresh air in the MDM world. So fantastic, that makes me excited. You mentioned that you know, in scoring the MDM there’s a complexity data and risk and we sort of dove into some of how the complexity gets scored. But Jason, do you have a structure to help clinicians guide, what level of charting that they are creating as they go through seeing a patient?

Jason D. Adler: I do, and the structure includes the four S’s, what we call the four S’s, You’ve got stories studies, shared decision, making and then social determinants of health. And to start off with stories. That’s a big one because that’s converting and speaking to the to our clinical colleagues. What the coders would see as the data category. Stories involves involves your non-patient sources of information information obtain that doesn’t come directly from the history that you already took from the patient. The first element would be your independent historian. That could be EMS. It could be an urgent care or a referring clinician. It could be family members. All of those individuals give you information to help support your care of the patient. Just imagine a patient who comes in aphasic, Potential stroke. You get information from EMS and then an hour later you get a call or you make the call to a family member and you get a different last time known well. By documenting what information came by EMS and doing it contemporaneously and then subsequently, What information came from that family member. How does that affect your treatment right? That might change your approach to managing a potential stroke patient. Documenting tt not only creates a more coherent chart with accurate information, but it’s reflected in the data category of the grid under Independent Historian. The second component or element would be the review of external records and this is a bit new for us because the old language.  Would say Old Record Review. Now there’s a new definition, we’re looking at external non-ed records, and what that means, is any record that you look at, that doesn’t come from your own department. That’s the position of ACEP. And they’re very clear, it’s not your own department but could be any other place that information comes from, so it could be that EMS note. It could be an inpatient note, or discharge summary. It could be an urgent care note, could be outpatient records. If you see a patient who comes in, who you’re concerned for sepsis or septic shock. And this is probably not the right venue to discuss whether that 30cc per kilo bolus is good or bad medicine, but we often will look at a discharge summary or previous echo to determine whether that bolus may or may not be subsequently given. By documenting review of external record: “Previous echocardiogram this date with these results.” That puts it in the medical record your thought process of how you made the decisions that you subsequently made. And at the same time, that’s part of the data category on the coding grid. So, the first element would be your independent historian. Your second is the review of external records and the third is management of discussions with physicians or appropriate source. Now. With physicians. That makes sense. You’re talking about the hospitalist and consultants and I believe our community does a very good job of that in documenting that But think about the radiologist, having a conversation when they call over and tell us about a result. Or we might see a patient who comes in with, right lower quadrant pain. Have persistent tenderness CT, may be right? Is negative. Your repeat exam you might well, call radiologist and have that conversation. ”Actually. You know what? I see this.” That conversation for that work performed is credited under discussion of management, with physician or appropriate source, very valued in these guidelines. And if you’re having that conversation, it should be in the record. And appropriate source is new. That wasn’t in the 95 guidelines. That includes discussions with your mental health liaison, maybe ESPERT, pharmacy, social work. We live and breathe in a physician led team. And we work with a number of colleagues that support the high quality care that emergency medicine provides. And if you’re coordinating care for a patient with an acute psychiatric, or mental health, emergency, that patient may be boarding. There might be colleagues of yours and ours who are trying to find this patient a bed. We’re have conversations and seeing what is going on and what we can do to advocate for them. Those conversations are meaningful towards patient care and they’re all so highly valued within these guidelines. so, under the stories category, and non-patient, non-patient Sources of information, we’ve got the independent historian, your review of external records, and your management discussions with physicians or appropriate source, appropriate source, being brand new for 2023.

Jason Hine: Wow. That was a that was a lot of awesome information. So our first S Stories and as you said, so non-patient sources of information medical record review, and then conversations with other care team members, I want to pin you down a little bit because some of this is a little confusing for me. You know, we have the the non-patient source of information and we have the external to our emergency department record review, but then there’s sort of the management conversations that we’re having and sort of who qualifies who gets that that badge on their their scrubs or on their their chest of being important enough or valuable enough to the patient care to sort of count in that category? And man, this can run the gamut, right? We have the patient’s nurse, probably not, pharmacist, radiology tech, radiologist, PT, Case management, sort of who in that spectrum is gonna fit into that category of being another person sort of consulted on the care of the patient?

Jason D. Adler: It’s a great question. So we are actually talking about discussion of management with a physician QHP or appropriate source. And for the intent of this discussion, we can combine those three into a broader category of- We know who the physician is- That’s your consultant, your hospitalist, any physician that you speak to and QHP an appropriate source really does have a broad range of possibilities of individuals who would qualify for that. To your point, that would include your Pharmacist Your Mental Health Liaison, If you have SBERT, you’ve got case management and social work. It could include people outside the hospital you speak to about the patient’s care. It could include a number of individuals that work within our team to support the care of the patient.

Jason Hine: That’s interesting.

Jason D. Adler: The guidelines reference specifically For the purpose of discussion of management data elements. And we’re talking about appropriate source here, maybe involved in the management of the patient. For example, lawyer parole officer case manager teacher, that’s external. And it does but does not include discussion with family or informal caregivers. So generally individuals within the hospital on the healthcare team and generally individuals in the hospital on the healthcare team. And certainly would include pharmacy social work case management, SBERT, respiratory therapy, generally are considered to be an appropriate source.

Jason Hine: Perfect. So coming to external record review. You said, essentially, it’s any bit of information or records, that are taking from outside of our the walls or, you know, the existence of our emergency department. Can you give me a little bit more detail of what that might look like? Or what types of records would be included in that category?

Jason D. Adler: Yeah, external record review generally includes those inpatient notes, if you have studies performed within the hospital, maybe a discharge summary prescription drug monitoring program. If you have access to that, where the through the EMR or through a separate website, where you can see medications that were given to somebody. It includes an EMS run report. It’s any type of medical record that was generated outside of your own department and that supported by the FAQ’S at ACEP.

Jason Hine: Okay, excellent.

Jason Hine: And the last little area on this, that this might be specific to me, but I’m wondering if other people have this. Now, our epic has some sort of click boxes within the MDM history from significant other EMS, blah blah but it doesn’t really delineate what history are we getting? It’s just saying that it’s obtained from elsewhere. Is records are reviewed from outside. Doesn’t say what record or whether it’s a discharge summary or an echo. Are these details important Jason? and if so how do we sort of quantify or qualify them where the information is coming in?

Jason D. Adler: It’s a really good question, Jason and you really should quantify and qualify what we are speaking to, We have seen EMRs potential templates that exist out there that may have a button at the top of where you got your information, you could click a dozen different things and then you just create your own narrative with maybe some dictation software or free text. 

Jason Hine: Okay. 

Jason D. Adler: in terms of no quality, documenting what you obtained from where, and from whom not only creates a more coherent record, but it makes a long-standing medical record that another person could read and understand how you got your information and what that’s it being used for.

Jason Hine: Okay and so it sounds like throughout this conversation, a theme that’s coming to light for me is “tell a story.” you know, as you’re going through that MDM, you say, you know, as per EMS patient last known well, at this time. Call to nursing home notes, a different time of last known. Well, you know, external sources of information, you can click those boxes as well. But if you’re putting it into the paragraph or the story that you’re writing, that’s that’s really where you get the the meat of the information itself. Is that fair to say?

Jason D. Adler: It’s absolutely fair to say and you really keyed in on a really important topic. There is, “Where do I have to write this stuff?” We’re talking about medical decision making, and that might be at the bottom half of the chart. But it’s we’re talking about the history part. There is… the medical record stands on its own merit. And that’s an important statement to make moving forward. Even though history obtained from an independent historian is scored by the coder as part of medical decision making, there’s no rule of where in the chart it would need to be placed. In other words, if we follow our natural, cadence, and flow of making a medical record, The History section is where you would likely include the history obtained from an independent historian 

Jason Hine: Right.

Jason D. Adler: That’s the History section. May also be the area that you include the External Record review. If you look at the EMS Run report or run sheet, or if you look at that old echocardiogram and document external record reviewed: “Previous echo.,This facility. For 2022. Preserved, EF period paragraph.” That information actually is clinically meaningful and follows a cadence. And rhythm of the way that we would make our charts to minimize the time that we are at the EMR and then also gets captured by the coder as well. Really does find the middle of that Venn diagram

Jason Hine: Okay, I like that. And I like when you start doing your your talking, I can tell you’re talking into like the Dragon mic, you know,…

Jason D. Adler: There you go.

Jason Hine: Period, new paragraph. It’s just “oh, he’s dictating right now.” Okay. But onto our next S. S1 was stories. S2 studies. What do you mean by this, Jason?

Jason D. Adler: So studies. There’s an area on the grid that we’re still in the data section that involves studies, and studies can be labs images or tracings that are ordered or reviewed. And generally when something is ordered, it’s also reviewed in emergency medicine. And that’s not really documentation-dependent, that’s Action-dependent. But, there’s a heightened sensitivity and an increased importance of an independent interpretations. And that’s where that Studies comes from. Independent interpretations are very heavily weighed in these guidelines in the medical decision-making grid, your independent interpretations can be related to your EKGs your X-rays CTS and then ultrasounds any thing that you’re not separately billing for will count in that category related to the medical decision-making grid. Now, we have to get rid of the old muscle memory that we had based on these old guidelines. You talked earlier about “all systems reviewed and negative” that was old muscle memory. There’s also old muscle memory related to interpretations because the old language was Reviewed. There was a lot of words, surrounding reviewed and ordered. And if you were to write, for example, “test, X-ray shows,” we’re On Dragon again ”chest, X-ray: chest X-ray, no obvious infiltrate.” That would not be credited in these guidelines. The language that we need to use when performing an independent interpretation would be. “Chest X-ray, per my interpretation, no obvious infiltrate.” The word interpretation needs to be documented in order to get credit based on these guidelines 

Jason Hine: Hmm. Okay, so it’s interesting. There’s a change in nomenclature, not reviewed but interpretation. That’s kind of the new buzzword. And now what about labs? Is there anywhere that that comes into play? We independently interpret labs all the time.

Jason D. Adler: That’s correct. And the labs data category is for just an order or just review. So that’s an action that you are going to do whether you order it or not order it. But it’s not documentation dependent. The independent interpretations are very documentation dependent and the words used really do matter. So there’s a heightened emphasis on the independent interpretations. But to answer your questions directly, there’s no requirement to say that you reviewed or interpreted a lab study. Now, there’s clinical reasons to do that. There’s lots of positive clinical reasons to discuss the white count and lactate, and other lab abnormalities that that or normalities that you see, it’s just not recognized in the way that the independent interpretations of ekg’s chest X-rays, those separately reportable interpretations that you would typically, or could be billed that you are not billing for., but we often aren’t. In many cases, we aren’t billing for the images, so by describing that you would capture the cognitive work that you’re performing when you are doing it and you document it, you will be credited.

Jason Hine: Alright. So S1 stories. S2 studies. We’re coming into S3 shared decision making. What does this mean? And How does it really come into play for our chart levels?

Jason D. Adler: So there is a value on shared decision making in this set of guidelines, which is really refreshing because in our modern climate of medicine, we want to be hypersensitive towards joint shared decision making. And in this case, the guidelines acknowledge that. So if, for example, and I think the most common one that’s offered involves the HEART score where you could choose a pathway of one set of troponin. Two sets of troponians, observation versus discharge, you have a discussion about the major adverse cardiac event. Likelihood you go through that, you have that conversation about disposition that conversation really involves a consideration of an escalation of care. And when you have that consideration of an escalation of care that that is very heavily weighed within the guidelines as well, if you consider to bring the patient to a higher level of care, whether to be the observation or inpatient status, documenting that that conversation occurred and as part of that conversation, there was a discussion about escalating the care, That is heavily weed within the guidelines. That’s part of the risk table.

Jason Hine: Okay. Yeah, I was wondering.. I was wondering a little bit. We talked about sort of these three columns complexity data and so we’re coming back around full circle to risk. When we do share decision, making and the the risk comes into play in those conversations, I’m wondering, you mentioned a mission versus discharge. Do you want to stay in observation? What about, you know, need for testing? Okay, you’re, you’re 18 years old, you know, we have a consideration for this potential injury or pathology. The only way unfortunately to diagnosis is through. CT scan, let’s talk about radiation does exposure and what you as a individual want to do would that in that same category?

Jason D. Adler: So the shared decision making and we just use the HEART example to talk about consideration of escalation of care, that’s under the high risk section and if you’re having a conversation about escalating care and by the way, it’s also true for consideration or decision to de-escalate care. If you could imagine a scenario whereby, someone has a catastrophic brain injury, and you consult neurosurgery maybe you get the ICU involved. There’s a family discussion and the final outcome is we are not going to transfer to a tertiary medical center. Quaternary medical center. We’re going to de-escalate care into the palliative realm and maybe admit to a hospital bed or work out hospice with case management. That’s actually also considered high risk so just to close out the conversation on consideration of escalation of care,…

Jason Hine: Mmm.

Jason D. Adler: there’s also that component of consideration or actively de-escalating care which involves the risk table as well. And that’s on the high risk side of things. You’re brought up a really good point though because you referenced the consideration of studies. And that’s another element of these guidelines that are really forward thinking and contemporaneous. We are hypersensitive about CT over utilization. We are hypersensitive about antibiotic resistance and having good antibiotic stewardship. And compared to the 95 guidelines, there’s a key distinction that are offered in this set that we are under today. If you document and describe your cognitive thought process, and we’re talking about the “thinking and ink.” What you are thinking about doing, but end up not doing and in some cases as it relates to labs or images and medications if you considered but don’t do or order, then you get credit as if you had so long as that it’s documented. Now that was a little bit long-winded, I’ll just give an example. if you see a patient who comes in with an upper respiratory infection, maybe they’ve got a sore throat, you order a covid swab maybe order strep swab. It maybe the patient has a cough. You document you considered ordering a chest x-ray, but not consistent with a bacterial pneumonia or low suspicion for bacterial pneumonia and Most likely consistent with the viral etiology. Therefore antibiotics will not be given. You would get credit for that chest X-ray. In the antibiotics, even though neither of which were ordered or prescribed and that would define in this example, a Level Four visit. so,…

Jason Hine: Hmm.

Jason D. Adler: These guidelines value, the cognitive work that we are doing and when documented Are credited in a way that’s beneficial and contrast that to the 95 guidelines that valued just mouse clicks, you ordered medications you got credit you ordered a CT, you got credit. If you consider but don’t perform and in, Cluding with the shared decision making you would get the same credit as if you had actually done it, which is high quality low-cost care.

Jason Hine: Well, there’s a lot of awesome stuff in there first. First think in ink. What a great little phrase about how we should really be electively. Considering these new infrastructures documentation, and how we should be putting our mind to page. I feel like maybe you, you have that tattoo, that should be somewhere on your body: think in ink. It’s just, it’s a perfect way of putting this together cognitively in such a overarching theme of everything that we’re doing when we think we want credit for it. Put it in ink.

Jason D. Adler: I love emergency medicine. We take care of the undifferentiated acute episodic care of the patient, undifferentiated acute unscheduled care. The things that go through our mind Jason, on a day-to-day basis and seeing patients and the considerations of high acuity, low occurrence, differential diagnosis, consideration of advanced diagnostic testing, when to order, when not to order, when a patient needs to stay in the hospital, when they’re safe to go home. The cognitive intensity is fairly high. And in my opinion, these guidelines value that intensity when it’s documented. And it comes out all over this grid, these guidelines more align with the bedside work we’re doing today compared to the old guidelines that were very EMR heavy.

Jason Hine: Perfect. And I think that that highlights two points where, you know, we’re in S3, we’re talking about shared decision making and so that conversation with the patient, you know, I would imagine. Even if you’re, if you’re sort of, you know, quote Unquote, talking someone off the edge, You know, I, I think I have bronchitis. I’m, you know, ready for my chest X-ray, that they gave me every time. You talk with them about that. You explain why that may not be necessary. That’s still part of the shared decision-making process but you also highlighted, you should be getting credit for tests that you consider and not order or not, even test, test therapeutics, anything that you consider and not order. And this might be an area where these small dot phrase could be valuable not the entire differential for chest pain, but “patients presentation consistent with URI, you know, considered antibiotic administration, considering comorbidities, antibiotics stewardship, you know, decision not to administer.” That’s something that you might be using routinely, you know, in the months from October, through through April. But the tests and therapeutics that you’re considering, but not giving and the shared decision making that you’re doing with the patient. Both of those are very valuable.

Jason D. Adler: They’re valuable in terms of treating the patient and communicating information to the next healthcare provider and it’s they’re valuable in terms of anybody else that reads that chart and they’re recognized within the guidelines. It’s much better alignment than what we had 28 years ago. 

Jason Hine: Perfect again, me excited man. You got me excited for the changes that we’re seeing. EMR. Documentation, is not all bad. It’s not all bad. all right, the fourth, the final S4. Social And of course, here we are talking about social determinants of health. These elements come into the care all the time. But in my opinion, it seems kind of like to be often in these really intangible ways. We think second time that they came into the ER this week, this person kind of they live alone. We got to reconsider our normal algorithm for disposition. You know, that happens to us routinely. But how are these social determinants of health coming to the fore in the 2023 documentation? 

Jason D. Adler: Yeah. Social determinants of health are certainly incorporated into these documentation guidelines. They’re scored under the moderate risk category. And what we are talking about are economic and social conditions that influence the health of people and their communities. Practically speaking, I think all of us have been in a position where we’ve given a patient an inhaler. With an order of 1 puff and then they keep the inhaler because you know they lack the ability to get that medication on their own outside of the hospital. Maybe in the past there was situations where you would use cab vouchers and maybe currently there might be a arrangement with a rideshare program, Uber or Lyft, where we help people get home and arrange safe transportation home. Patients who have social determinants of health are actually incorporated into the medical decision-making grid as well, and it’s scored as moderate risk. Jason, I’d like to shift for a moment away from the coding grid and the documentation discussion to talk about social determinants of health. It’s true that they are on it and it’s scored at moderate risk, 

Jason Hine: Okay.

Jason D. Adler: There are also Z codes which are diagnosis codes. That are connected to social determinants of health. Now, we’re not talking about the evaluation of management 1 through 5 codes. That what we’ve been talking about the entire time with these guidelines, 83% of total RVUs out there. We’re talking about the diagnosis coding, and that’s a separate discussion compared to the codes that we were talking about the diagnosis codes come from ICD 10. We’re talking about the International Classification of Disease, and that code set is trademarked by the World Health Organization. And the intent of this is for epidemiologic tracking of illness and disease. Jason, can you think of a time in the past two years or three years where there is value in epidemiologic tracking of illness and disease?

Jason Hine: Hmm, I think you’re sending me setting me up. Yeah, I got one in mind.

Jason D. Adler: Almost all of the COVID data that we have comes from diagnosis lines and from that ICD10 code set. So we cannot identify track and treats without visibility. You can’t treat anything until you see it. And as it relates to social determinants of health, the Z codes if you put them on that diagnosis line. Now we can see what we’re doing in our departments and the patients that we’re seeing in our department, you could raise visibility and yes, it’s scored on the medical decision-making grid. And at the same time, if you add it to your diagnosis line, you enhance visibility. And if multiple people do it in your hospital, the numbers get bigger. If people do it in your state, then it becomes highly visible. And that could shift Medicaid funding. If multiple people in multiple states capture. Diagnosis that include social determinants of health, and we’re talking about lack of transportation, homelessness, insufficient social insurance. Then you’re talking about the potential to change national healthcare policy. It’s much bigger than a one chart discussion. Pulling back to where we started, it is true if you document the patient’s care was significantly impacted by a social determinant of health and offered some context around that. It is scored on the medical decision-making grid. But to me, the story about SDOH is much bigger. Than just one chart. We could talk about national policy.

Jason Hine: Wow man that was that’s like that. I mean that’s uplifting in its own right. Like it’s the the many little things that come together that can actually bring about change in the system and wow to unpackage that collectively. We’re going to put it into our, you know, our medical decision, making the social determinants, how they impact the care of the patient. The way in which we are treating them, even their disposition. That is something that we’re going to be putting, you know, thinking and ink putting it down as part of our MDM. But the idea of sort of the diagnosis line of putting some of those social determinants, into their diagnosis and how that can create essentially, you know, a digital paper trail that can be followed to recognize the impact of, you know, psychiatric illness in care of patients food insecurity, you know, access to housing,  all of that stuff if that can be put together through the connection of millions and billions of small dots, it can actually affect the way that we fund and eventually are able to provide care for patients in the future.

Jason D. Adler: Absolutely. And again, we’re talking about these new guidelines that are related to coding and reimbursement and at the micro level it’s or the chart level. Each of these elements that we’re talking about matter and contribute to showing the great work that our community does every single day. The one element involving social determinants of health has the potential to be much bigger than any single chart. That said, just for clarity, to be scored on a single chart, we need to be clear that the social determinant of health significantly impacted the care of the patient. And that’s the language that’s used in the guidelines and what’s recommended to use the medical record and when we talk about the bigger picture of changing National policy. That’s where you can use the diagnosis line.

Jason Hine: Okay, interesting. Yeah. Certainly, you know it you’re only gonna get the the credit if it’s actually impacting your MDM, it’s impacting your decision making that makes sense. Ok. So, Dr. Adler Jason. The other Jason in this conversation. We went through a lot today. We’re we were finishing up our S’s, right? So S1 stories, S2 studies. S3, shared decision making. And then we just wrapped up with S4 social, meaning social determinants of health. This has been super informational for me, it’s opened my eyes to what this is for, right? The the thought processes, the reason behind the changes that we are all seeing and doing now, but I wanted to ask you, we’ve had the structure for charting and billing for a few months now. What have you learned to sort of in the post implementation side of things that you wish you knew before or would want to relate to our listeners?

Jason D. Adler: Great question, Jason. So these guidelines were released in July of 2022. They became effective on January 1 of 2023. We now have about 75 days worth of experience working within it. I know the transition was a little bit challenging as you worked through it clinically and since then in speaking to colleagues around the country and those involved with the industry, it seemed as though one the charts are getting shorter, Two- there’s a more clear cohesive nature of the way the documentation that exists seeing a lot of reduction in the review of systems and the exams sections or shortening up. So there’s a reduction of note bloat and it seems as though that what these guidelines value are more aligned with what we do as emergency physicians and creates a very nice harmony of work and time at the EMR now. Is it perfect? We’re just over two months, three months in now. Not. No, not yet. And we’re still getting our rhythm. We’re still getting our cadence, though. There is reason to be significantly optimistic and excited about the future.

Jason Hine: I would agree with that and I love that you’re looking toward perfect. Yeah, an improvement from terrible seems like a great step in. It seems like we definitely are making strides towards value towards valuing our thought processes towards all of the work that we do in working through these very complex, Emergency Department patients from the patient the history Through all of the underlying medical problems that come into our differential, the number of people that we work with, in the hospital and in the outside world, to come up with the right plan for the patient and then talking with the patient and their family members about that plan. It’s all actually being valued and man, it feels good to be valued, right? It feels good to be valued for the work and time and you know, blood sweat and tears really that we put into our patient care. So Jason Dr. Adler, thank you for breaking this down with us again. Very informative for me, folks, in the show notes, We will have a structuralization of this for you so you can bring it to your next shift. There’ll be plenty of references, resources and of course Dr. Adler’s point of contact if you want to reach out to him or have any questions. Jason, Dr. Adler, thank you so much for joining us.

Jason D. Adler: Thank you.

The New Guidelines – Overview

The guidelines released in 2023 are meant to help with “patients over paperwork” and empower clinicians to provide care and put what is important and relevant in the medical record. In the end, it all comes down the the Medical Decision Making (MDM). Nearly all of the “points” we get for the level of charting and care we provide will be found in the MDM. Dr. Alder has a structuralized approach to how we chart and the level of charting we do.

The 4 S’s

The changes in billing can be broken down four simple areas, which can be represented by The 4 S’s.

1. Stories

The data category on the above chart. Information related to the patient that does not come directly from the patient themself. This includes:

  • Independent Historian
  • Review of External Records
  • Discussions with physicians, qualified health personnel (QHP), or appropriate source

2. Studies

Labs, imaging, or tracings that are ordered and reviewed by the treating provider. It is important to note independent interpretation of these for maximum credit.

3. Shared Decision Making

The conversations with have with patient’s about the direction of care and how that works within their personal, religious, financial, or other lives. This can include:

  • Discharge, observation, admission decisions. This is really where the guidelines focus on shared decision making
  • Imaging and therapies. Where or not to do the CT in that young patient, to employ watchful waiting for acute otitis. These are shared decisions too.

4. Social Determinants of Health

There is a huge swing in focus of how a patient’s social circumstances affects their overall health. While this can manifest in many ways, common ones include:

  • Lack of transportation, homelessness, insufficient social insurance – Dr. Alder points these out a key areas of focus
  • Mental illness, substance use disorder
  • Literacy, social support structure (lives alone vs with others), among many others

General Principles & Conclusions

Remember think in ink. ALL the things we think about and do, as well as not do should be put onto the patient chart and will be credited for the work that we do when it comes to billing.

Globally, these guideline changes are intended to more accurately represent the work we do cognitively in diagnosing and treating patients- accounting for all the steps from the history we get from many sources, to the targeted differential we build, the steps to working that differential up, and finally all of the communication with consultants, other care team members, the patient, and the patient family in enacting a plan that is most likely to succeed. Are the guidelines perfect? No, but it appears to be a refreshing step away from payments based on EMR clicks and ordering a bunch of stuff and toward the provision of quality care.

If you have questions or would like to dive in more, check out the links below in the References & Further Readings section. You can also reach out to Dr. Jason D. Alder via email at

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References & Further Readings

[1] American Medical Association: Evaluation and Management (E/M) Services Guidelines (PDF)

[2] American College of Emergency Physicians: MDM Grid (PDF)

[3] American College of Emergency Physicians: FAQs (website)

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