In simple words: The provider sees a patient for an emergency department visit involving evaluation and management (E/M). The visit involves a moderate level of medical decision making.

Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

Example 1: A patient presents to the ED with severe abdominal pain, nausea, and vomiting. The physician performs a detailed history and examination, orders laboratory tests and imaging studies, and diagnoses appendicitis. The physician consults with a surgeon and admits the patient for an appendectomy., A patient with a history of asthma presents to the ED with shortness of breath and wheezing. The physician performs a problem-focused history and examination, orders a chest X-ray and pulmonary function tests, and diagnoses an asthma exacerbation. The physician prescribes medications and discharges the patient home with instructions for follow-up care., A patient presents to the ED after falling and injuring their wrist. The physician obtains a detailed history, performs a detailed examination of the wrist, and orders X-rays. A fracture is diagnosed. The physician applies a splint and refers the patient to an orthopedist for follow-up care.

Documentation should include a medically appropriate history and/or physical examination, the level of medical decision making (MDM), and any counseling and/or coordination of care provided. All services performed should be documented in the medical record.