How E&M Code Changes in 2023 Will Impact Nursing Facility Services

This category of E&M services will have three subcategories instead of the current four.

EDITOR’S NOTE: The American Medical Association (AMA) announced major revisions to Evaluation and Management (E&M) Services for Jan 1, 2023. The E&M categories that will undergo revision in 2023 include inpatient and observation care services, emergency department services, consultations, nursing facility services, home and residence services, and prolonged services.

For 2023, revisions to the E&M category for nursing facility services include a deleted code, revised codes, and broad guidelines revisions. In 2023, this category of E&M services will have three subcategories instead of the current four: Initial nursing facility care, subsequent nursing facility care and nursing facility discharge services. The nursing facility annual assessment code, 99318, is deleted with parenthetical reference to report this service with the subsequent nursing facility care codes, 99307-99310. 

The subsection guidelines now indicate that these services are reported for E&M services to patients in nursing facilities and skilled nursing facilities. These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center and immediate care facility for individuals with intellectual disabilities.

Regulations pertaining to the care of nursing facility residents govern the nature and minimum frequency of assessments and visits. These regulations also govern who may perform the initial comprehensive visit.

Revisions to the remaining E&M categories, including Nursing Facilities Services, align the 2023 E&M codes with the 2021 revisions made to the office and other outpatient services codes. The three key components, history, exam, and medical decision making are no longer required for reporting these services. A medical appropriate history or physical as determined by the physician or APP should be documented; the level of service is determined solely be the level of medical decision making (MDM) or time. The AMA redefined what “time” includes for selection of the level of service, time is now the total time on the date of the encounter and includes both face-to-face time and non-face-to-face time.  Activities included in total time are the following:

• Preparing to see the patient
• Obtaining/reviewing separately obtained history
• Performing examination
• Counseling and educating the patient/family
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals
• Documenting in the electronic health or other health record
• Independently interpreting results and communicating results to patient/family
• Care coordination (when not reported separately)

The revised guidelines state a high-level MDM-type specific to initial nursing facility care by the principal physician or other qualified health care professional is defined as multiple morbidities requiring intensive management. Moreover, it is also defined as a set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations.

The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital. The principal physician is the physician who oversees the patient’s care as opposed to other physicians or qualified health care professionals who may be furnishing specialty care.

Initial nursing facility care codes 99304, 99305, 99306 may be used once per admission, per physician or other qualified health care professional, regardless of length of stay. They may be used for the initial comprehensive visit performed by the principal physician or other qualified health care professional. Skilled nursing facility initial comprehensive visits must be performed by a physician. Qualified health care professionals may report initial comprehensive nursing facility visits for nursing facility level of care patients, if allowed by state law or regulation. An initial service may be reported when the patient has not received any face-to-face professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the stay.

I have shared the code revisions for nursing facility services and a few of the key guideline revisions. If your providers see patients in nursing facilities a complete review and understanding of the coding and reporting guidelines is essential to proper payment. Coding professionals should be aware of these revisions because they will affect reimbursement. Consider reviewing current documentation practices and revise documentation templates not needed for patient care. Also consider how your providers can track total time in to correctly report and bill for these services.

Programming note: Listen to Colleen Deighan’s live reporting on E&M updates today during Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer at 10 Eastern.

References:

American Medical Association 2023 E&M Code and Guideline changes, available at: 2023 CPT E&M descriptors and guidelines (ama-assn.org)

Billing and Coding: Evaluation and Management Services in a Nursing Facility, available at https://www.cms.gov/medicare-coverage-database

AMA CPT® Professional 2022 Codebook © 2021 American Medical Association

AMA CPT® Assistant, August 2022, Pg 3,  E&M Revisions for 2023: An Overview