2023 E&M Revisions Warrant Study to Prevent Denials

Colleen Deighan and ICD10monitor are producing an editorial series to report on the updated changes from the AMA.

EDITOR’S NOTE: This morning, Colleen Deighan continues the second installment in her series of updates to the evaluation and management (E&M) codes and guidelines from the American Medical Association. The E&M revisions are effective Jan 1, 2023.

The E&M categories that will undergo revision in 2023 include the following:

• Inpatient and observation care services
• Consultations – both outpatient and inpatient
• Emergency department services
• Nursing facility services
• Home and residence services 
• Prolonged services

My goal each week over the next few months is to focus in on one E&M category, taking a deeper dive into the revisions and guideline changes. In addition to the E&M category revisions, I will lay out the details of the revisions made to the elements of medical decision making and time, so you are prepared to accurately apply the revisions.

As documentation integrity and coding professionals our role is to ensure the E&M level of service reflects the services furnished during the visit. That includes assigning or validating the E&M codes based on provider documentation, and provider education all important links in the revenue cycle.

Hospital Inpatient and Hospital Observation Services

Beginning Jan. 1, 2023, the changes will be effective:

• Hospital Observation Services categories and E&M codes will be deleted
  • E&M codes 99217, 99218-99220 and 99224-99226
• Hospital Inpatient services categories and E&M codes have been revised and titled:

• Hospital Inpatient and Observation Care Services
• E&M codes 99221-99223, 99231-99233 and 99238, 99239
• Observation or IP care Services including admit and discharge on same date are retained
  • E&M codes 99234-99236

In addition to the revisions to the E&M categories themselves the criteria for E&M level assigned has huge changes. The American Medical Association (AMA) CPT® editorial workgroup had a shared goal with the Centers for Medicare & Medicaid Services (CMS) in revising E&M services to reduce administrative burden and decrease unnecessary documentation not needed for patient care.

To accomplish this goal, the history and physical exam (H&P) will no longer be a component for E&M level selection. The guidelines state a medically appropriate H&P as determined by the physician/advanced practice provider (APP) should be documented and the level of service based on medical decision making or total time as the sole criterion for level of service selection. These revisions align with the revisions to New and Established Office and Other Outpatient Services that became effective January 1, 2021.

Official text to the E&M categories for Hospital Inpatient and Observation Care Services reads as follows: “… which requires a medically appropriate history and/or examination and straightforward or low, moderate, or high level of medical decision making within the three levels of service for initial or subsequent care.”

Additionally, floor/unit time has been revised to read “total time on the date of the encounter.”

The three elements to the levels of Medical Decision Making (MDM) include the following:

1. The number and complexity of problem(s) that are addressed during the encounter
2. The amount and/or complexity of data to be reviewed and analyzed.
3. The risk of complications and/or morbidity or mortality of patient management

These three elements are familiar but valuable words were added to each element to reflect the actual work of the physician/APP. Retained from prior years, the level of medical decision making is based on meeting two of three elements of MDM.

For coding purposes, time for these services is redefined as the total time on the date of the encounter. This includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/APP on the day of the encounter. It includes time regardless of the location of the physician or advanced practice provider (APP). 

With the revision of unit/floor time to total time, the ranges of time are changed; be sure to review and incorporate total time and the ranges to a given code into your education and learning.

The following is the schedule of presentations during Talk Ten Tuesdays, 10 Eastern.

Resource:

American Medical Association CPT® Evaluation and Management (E&M) Code and Guideline Changes available at: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management