You interpreted the image, called the consultant, and weighed treatment options. Make sure your note captures your work and thought process, including details that coders cannot otherwise infer, to earn accurate compensation under the 2023 evaluation and management (E/M) guidelines. Here are four high-yield habits affecting your medical decision making (MDM):

1. Describe the diagnoses you considered. “Considered cord compression, but no red flags and neuro exam normal.” Any competent emergency physician asks for red flags and checks for neurologic deficits in a patient with acute lower back pain and radiculopathy. Cord compression is a high-risk diagnosis that, if not explicitly stated, will not be considered as addressed by the nonclinical coding group.
2. Record your independent interpretation. “My interpretation of the chest X-ray: no focal infiltrate,” or your independent ECG interpretation is often the difference between a level 3 and a level 5 chart. Discuss wording expectations with your coding group.
3. Capture consultant discussions and recommendations. “Discussed with cardiology who recommended admission.” Identify the consultant or specialty and summarize the actual management recommendation. A consult order alone does not meet documentation requirements—the conversation itself must be documented.
4. Explain decisions to defer testing or treatment. “Considered antibiotics, however viral testing positive for RSV so will defer” or “considered head CT, but patient very low risk for intracranial traumatic findings per Canadian CT Head Rule.” Describing your thought process can give you credit for difficult, long conversations with patients, even if you don’t go the extra step of labs, advanced imaging, or certain medications.

These details document work you have already performed, and go a long way toward capturing higher E/M levels. Each level jump can lead to additional relative value units per patient encounter.

Disclaimer: Opinions expressed in this piece do not represent the views of ACEP nor ACEP official policy.

Dr. Mostaghimi is senior clinical director of the Massachusetts General Hospital Emergency Department and medical director for emergency services at Mass Eye and Ear in Boston. He serves on ACEP’s Reimbursement Committee, with professional interests in emergency department operations, care delivery innovation, and reimbursement policy.