Best Practices: Overcome 2023 E/M Update Challenges with Expert Advice

Why This Topic Matters

The 2023 E/M update changed long-established inpatient coding workflows, so teams need to recognize common documentation gaps and communication issues that can affect code selection, compliance, and training.

Article Sections

1. Challenge 1: Habits are Hard to Break

   Discusses how long-standing documentation habits can make it difficult for providers and coders to adapt to newer E/M expectations. Focuses on the broader transition from quantity-focused to quality-focused documentation.

2. Challenge 2: Documentation Gaps

   Reviews common areas where records may lack enough detail for E/M assessment. Covers broad documentation topics such as risk, condition status, data elements, and differential diagnoses.

3. Challenge 3: Lack of Understanding of How Things Relate to MDM

   Explains how incomplete understanding of medical decision-making concepts can lead to vague documentation. Covers the broad relationship between presenting problem, risk, and data.

4. Challenge 4: Time

   Addresses general issues with documenting and using time in E/M coding. Notes concerns related to separately reportable services and electronic system behavior.

5. Understand How to Solve These Challenges

   Outlines broad process improvements for coding teams, including compliance review, training reinforcement, and physician query practices. Focuses on workflow and communication improvements rather than code selection specifics.