The SimKit Podcast Trimming the Fat of Note Bloat: 2023 Documentation Guidelines Broken Down with Jason Adler
Mar 21, 2023
In this engaging discussion, Dr. Jason Adler, a Clinical Assistant Professor at the University of Maryland and VP of Acute Care Solutions for Logix Health, dives into the 2023 updates to emergency medicine documentation guidelines. He highlights the shift towards prioritizing medical decision-making, reducing burdens on providers. The conversation also emphasizes the importance of concise notes, the role of social determinants of health, and the necessity of clear storytelling in medical records, all while enhancing accuracy and efficiency in patient care.
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MDM Now Controls Emergency Visit Coding
- The 1995 documentation rules were replaced on Jan 1, 2023 and history/exam no longer drive code selection.
- Code selection for 99281–99285 (≈83% of EM RVUs) is now determined primarily by medical decision making (MDM).
History and Exam Support Care Not Billing
- History and exam remain clinically important but are now focused on supporting care and risk rather than raising code level.
- The guidelines ask for a medically appropriate H&P to communicate with future teams, while MDM captures the cognitive work.
Write A Targeted Differential Tied To Your Workup
- Demonstrate complexity by writing a targeted differential tied to your workup and noting relevant comorbidities.
- Example: 'CT ordered to evaluate for ICH' or 'PERC negative; check enzymes for ACS' versus long dot-phrase lists.