The American Medical Association (AMA) has released changes to the Evaluation and Management(E/M) codes and guidelines set to go into effect January 1, 2023.
For new and revised CPT codes Current Procedural Terminology CPT 2023 brings with it 225 new codes, 93 revised codes and 75 deleted codes. And with the exception of anesthesia, there are coding and guideline changes in every section of the CPT codes 2023 set.
The most significant changes can be observed in the evaluation and management(E/M) codes for new and revised CPT codes.
There are 25 codes that have been eliminated and revisions to the introductory guidelines for five different categories of CPT codes.
- Level of E/M services will be based on the following:
The level of MDM (medical decision making) as defined for each service OR the total time for the E/M service performed on the date of the encounter. (Time spent by the practitioner includes face-to-face and non-face-to-face time.
- History and exam will no longer be used to select the level of CPT codes.
- Changes to the prolonged services code.
What Has Changed for Evaluation and Management(E/M)?
There are plentiful changes in this section and a thorough review is necessary. Before we dive into the modifications, let us look at what these changes mean for new and revised CPT codes.
- The centers for Medicare and Medicaid services’(CMS) 1995 or 1997 documentation guidelines for E/M services have been rendered redundant following the latest CPT codes changes.
- Henceforth, there will be only one set of guidelines for E/M services.
- Subsequently, the administrative burden on providers and coders will be greatly reduced.
- The MDM table has also been amended to enable usage with all other E/M categories where MDM is a coding option.
- There are clarifications and illustrations explaining where MDM can be used for code selection.
- The total time in the descriptors will no longer be calculated as a “time range” but instead will include the amount of time that must be met. For instance, code descriptor 99221 includes – 40 minutes must be met or exceeded.
- Consultation codes: office consultation code 99241 and inpatient consultation code 99251 deleted.
- Domiciliary code 99339, rest home code 99340 and custodial care services codes 99334 – 99337 deleted and merged with home services code 99341 – 99350 (except for deleted code 99343)
- Annual nursing facility assessment code 99318 deleted and replaced with subsequent nursing facility care codes (99307 – 99310) or Medicare G codes.
- Under the hospital observation services heading, observation care discharge service code 99217, initial observation care codes 99218 – 99220, and subsequent observation care codes 99224 – 99226 deleted.
- Prolonged services add-on codes (99354 – 99357) have been deleted.
1. INITIAL AND SUBSEQUENT SERVICES
A new section titled initial and subsequent services which applies to hospital inpatient, observation care and nursing facility codes has been added. It applies to both new and established patient visits. New and revised CPT codes under this title are used by physicians and other qualified health care professionals who have E/M services under their scope of practice. It clarifies the rules regarding physicians and other qualified heath care professionals who are working in the same specialty or sub- specialty in the same group practice.
To clarify, during an inpatient, observation or nursing facility stay, the group may bill ONLY one “initial service” and follow- up services will be billed with “subsequent visits”. This is aligned with the Medicare rule that physicians in the same group of the same specialty should bill and be paid as if they were on single physician.
2. CHOOSING A LEVEL OF SERVICE USING THE CPT 2023 E/M CHANGES
For the categories listed below, the level of E/M service can be selected by the medical decision making or time. New and revised CPT codes selected will be based on 3 primary factors: The number or complexity of problems addressed during the encounter, the amount and complexity of the data that needs to be reviewed or analyzed and, the risk of complications or morbidity or mortality.
HOSPITAL INPATIENT AND OBSERVATION CARE SERVICES
As codes 99217-99220 and 99224-99226 have been deleted, the same codes will be used to report services for patients who are in observation or are inpatient. Here two main set of new and revised CPT codes will be applied:
For when a patient is admitted and discharged on the same calendar day. (99234 to 99236)
For when a patient’s stay is longer than one calendar day (99221 to 99223) for the initial visit, (99231 to 99233) for subsequent visits and 99238 ND 99239 for discharge services for new and revised CPT codes.
Outpatient consultation codes (99241 to 99245) and inpatient consultations (99251 to 99255) were still active codes depending on where you are. However, as of 2023, 99241 and 99251 are deleted. Additionally, CPT codes says to continue using 99242 to 99245 for service in outpatient setting, including the home or emergency department and 99252 to 99255 for hospital inpatients, for observation level patients, for residents in a nursing facility and for patients in a partial hospital setting. A consult can be used only once per stay per specialty and group and can require a request from another healthcare professional and/or a written report.
EMERGENCY DEPARTMENT SERVICES
When selecting a level of service in 2023, use medical decision making. Time is not a factor here. New and revised CPT codes 99281 for the evaluation and management of a patient in an emergency visit now has a descriptor change. It is now defined as “emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
NURSING FACILITY CHANGES
New and revised CPT codes in this section are applied to patients in nursing facilities, skilled nursing facilities, psychiatric residential treatment centers, and immediate care facilities for people with intellectual disabilities. According to the AMA, there is high-level medical decision making specific to initial nursing facility cares by the principal physician (the admitting physician who oversees the patient’s care) or other qualified healthcare professional.
The AMA says that the initial nursing facility services may be used once per admission per physician or other qualified health care professional, irrespective of the length of stay. The AMA aligns itself with Medicare rules in saying that the initial comprehensive visit in a skilled nursing facility must be done by a physician. Initial services by physicians and other qualified healthcare professionals who are not the admitting or principal physician for the patient in the nursing home may be reported with initial nursing facility or consultation codes according to the CPT book.
The two nursing facility discharge services, 99315 and 99316 are time-based codes. They include all the time spent on the day that the physician or other qualified health care professional has a face-to-face visit with a patient. Report the service on the day that the practitioner sees the patient, even if it is not the same day that the patient is discharged.
HOME OR RESIDENCE SERVICES
Since domiciliary, rest home or custodial care services codes have been deleted, use the home or residence services cpt codes to report services to patients in those facilities.
For new patients: 99341, 99342, 99344, 99345 – (99343 has been deleted)
There are 4 levels of established patient home or resident services which use the codes 99347 – 99350. Note that while selecting a code based on time, you may not include the travel time.
3. PROLONGED CARE CODES
Prolonged care codes have received a fair bit of attention in the 2023 CPT E/M changes.
While face-to-face prolonged care codes (99354 to 99357) have been deleted, the non-face-to-face prolonged care codes 99358 and 99359 are here to stay for when the services are provided on a date other than a face-to-face visit. There is opportunity here because there are many services which may not be reported on the same date, and you probably never double count the time spent. Existing prolonged care code 99417 which currently may be used only with 99205 and 99215 will be reported with outpatient consult code 99245, home visit codes 99345 and 99350, and cognitive assessment code 99483 in 2023. A new add-on code (99418) describes prolonged inpatient or observation E/M services.
Commonly asked questions about the new and revised CPT codes answered by our coding experts at EMPClaims:
How do we define a new patient or initial visit?
A new patient is a patient who has not had a face-to-face professional service by the physician/ other qualified healthcare professional in the same group of the same specialty and sub-specialty in the past 3 years.
- If a patient transitions from inpatient to observation service or the other way round, is it considered the same stay?
Yes, it is considered as the same stay in this case. You may not bill an additional initial service.
- If a patient transitions between skilled nursing and nursing facility, in the same facility, is it considered the same stay?
Yes, it is considered as the same stay in this case.
- Will the same codes be used to report services for patients who are in observation or are inpatients?
Yes, one set of new and revised codes will be used for both observation and inpatient.