cliot (version 1.0.0)

em_coding_2023: 2023 Emergency Medicine Coding Guide (CPT 99281-99285)

Description

Calculates the appropriate CPT Evaluation and Management (E/M) code for Emergency Department visits based on the 2023 AMA CPT guidelines. The selection is driven entirely by Medical Decision Making (MDM), which comprises three components: 1. Number and Complexity of Problems Addressed (COPA). 2. Risk of Complications and/or Morbidity or Mortality of Patient Management. 3. Amount and/or Complexity of Data to be Reviewed and Analyzed.

The final code is determined by the "2 out of 3" rule: the code corresponds to the MDM level met or exceeded by at least two of the three components.

Usage

em_coding_2023(problem_complexity, risk_level, tests_ordered = 0, tests_reviewed = 0,
               prior_notes_reviewed = 0, independent_historian = 0,
               independent_interpretation = 0, discussion_management = 0)

Value

A list containing:

CPT_Code

The calculated CPT code (99282, 99283, 99284, or 99285).

MDM_Level

The overall Medical Decision Making level (Straightforward, Low, Moderate, High).

Component_Scores

The calculated level for each individual component (COPA, Risk, Data).

Data_Breakdown

Internal counts used to determine the Data complexity level.

Arguments

problem_complexity

String. Description of the patient's problem complexity. Matches MDCalc categories (e.g., "chronic illness w/severe exacerbation", "1 acute uncomplicated illness", "2 minor problems"). The function performs keyword matching to identify the severity level (Minimal, Low, Moderate, High).

risk_level

String. The risk level of patient management decisions. Accepted values: "High", "Moderate", "Low", "Minimal".

tests_ordered

Numeric (0, 1, 2, or 3). Number of unique tests ordered (e.g., Labs, CT, EKG). Input 3 if >= 3.

tests_reviewed

Numeric (0, 1, 2, or 3). Number of unique test results reviewed. Input 3 if >= 3.

prior_notes_reviewed

Numeric (0, 1, 2, or 3). Number of unique prior external notes reviewed. Input 3 if >= 3.

independent_historian

Numeric (0 or 1). Was an independent historian (e.g., parent, EMS, spouse) required? 1 = Yes, 0 = No.

independent_interpretation

Numeric (0 or 1). Did the provider perform an independent interpretation of a test (not separately billed)? 1 = Yes, 0 = No.

discussion_management

Numeric (0 or 1). Was there discussion of management or test interpretation with an external physician or qualified healthcare professional? 1 = Yes, 0 = No.

References

American Medical Association. CPT® Evaluation and Management (E/M) Code and Guideline Changes. 2023. ACEP. 2023 Emergency Department Evaluation and Management Guidelines.

Examples

# Example 1: 99285 (High Complexity)
# Severe exacerbation (High COPA), Prescription management (Moderate Risk),
# but Extensive Data (3 tests + Independent Historian + Discussion)
em_coding_2023(
  problem_complexity = "chronic illness w/severe exacerbation",
  risk_level = "Moderate",
  tests_ordered = 3,
  independent_historian = 1,
  discussion_management = 1
)

# Example 2: 99284 (Moderate Complexity)
# Acute systemic illness (Moderate COPA), Prescription drug (Moderate Risk),
# Minimal Data
em_coding_2023(
  problem_complexity = "acute illness w/systemic sx",
  risk_level = "Moderate",
  tests_ordered = 1
)