Q: Who is responsible for filling out the MDM section in EPIC?
A: For both PA & resident cases: the resident or PA should first fill out the MDM, just like the HPI/ROS/PE. Then, the attending should review it and make any desired additions or edits, in addition to writing their own note in the attending section of the note. For PA cases, the attending needs to document a substantive portion of the physical exam, HPI and make clear their plan in order to bill under the attending.
Q: Can I just ignore the new MDM template and free-text my MDM in the ED Course?
A: Technically, yes, but the 2023 MDM guidelines have very specific requirements. If you don’t use the MDM template, you would need to make sure you are meeting those requirements on your own, or else your chart may be down-coded. For example, if a patient presents in respiratory distress from asthma, simply mentioning that you treated their asthma would not get you to a level 5. Instead, a level 5 chart would require (among other things) that you document that their asthma represents a “severe exacerbation of a chronic illness”. The new MDM template is designed to make this easy, and to remind you to document various common things we do that are necessary for coding.
Q: Do I have to check any of the boxes in the MDM section?
A: No! Only check them if they apply to the patient. If none of them apply, then you might just have a low-complexity encounter, which is fine. For example, if the problem is “medication refill”, and the patient is stable with no acute issue, then you would not check any of the “threat to life”, “moderate exacerbation of chronic disease”, or “severe exacerbation of chronic disease” buttons.
Q: How do I use the Problem List? Do I need to do this AND a separate assessment and plan?
A: The idea is to write your assessment and plan for each problem! No need to write it a second time. If the problem happens to be a threat to life or bodily functions, or a chronic illness with moderate or severe exacerbation, you should check those boxes too.
Q: I have an idea for improving the new MDM template, OR a different question!
A: Please feel free to reach out to Brendan Connell and Nick Gavin (for issues relating to the Epic template), and to Erick Eiting (for questions regarding the new MDM requirements). We will be happy to help!
Providers should reference the following:
EM 2023 Billing Update – Video Presentation (YouTube Unlisted)
EM 2023 Billing Update Tip Sheet (Intranet)
EM 2023 Billing Update Chart Review Feedback (Intranet)
EM 2023 Billing Update MDM Grid (Intranet)
ACEP 2023 MDM Grid (Intranet)
EBM/FOAM Website
