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By: Mary Horkey, RCCIR, RCC, MSN-ARC
2023 Proposed Changes
The American Medical Association (AMA) has provided an early release of proposed changes to current Evaluation and Management (E/M) services effective January 1, 2023. These revisions resulted from the E/M workgroup’s agreement to standardize the rest of the E/M sections in the CPT code set, following the Panel’s acceptance of revisions to the E/M “office or other outpatient E/M codes” (99202-99215) for the CPT 2021 code set.
The panel review revealed two sets of guidelines emerged from the 2021 and 2022 sets. One of the sets included office or other outpatient E/M codes and the other represented any remaining codes. The result was an increased administrative burden for physicians, QHPs, and coders, “who have to divide E/M reporting across separate code families.”
The proposed 2023 revisions should result in codes that are more in sync with the rest of the E/M sections in CPT code set.
CPT Code Changes
Code changes include revisions to E/M guidelines, specific code revisions, additions and deletions. CPT changes include significant revisions of code definitions for inpatient services, deletion of low level consultation CPT codes 99241 and 99251, revisions to the remaining consultation codes (CPT’s 99242-99245 and 99252-99255) and the guidelines for these codes, revision of the prolonged service codes and guidelines and deletion of the observation CPT codes, with these services now assigned codes from the hospital inpatient code range.
With these changes (CPT) the Medical Decision Making (MDM) criteria implemented in 2021 for the office/outpatient codes now apply to all E/M codes, except those that are inherently time based, such as critical care.
While the patient history and physical exam are required to be performed as ‘medically appropriate’ (as determined by the provider), they do not contribute to the E/M code assigned. The visit code is based on either the level of MDM or the total time for E/M services performed relative to the patient on the date of the encounter.
Time for E/M Services
Time for all E/M services is now defined as the total time on the date of the encounter, both face-to-face time and non-face-to-face time personally spent by the provider.
All of the following can be included in the total time on the date of the encounter:
- preparing to see the patient
- obtaining/reviewing separately obtained history
- medically appropriate examination
- counseling and educating the patient/family/caregiver
- ordering medications
- tests or procedures
- referring and communication with other health care professionals
- documenting clinical information in the patient health record
The total time does not include any activities performed by clinical staff or when performing separately reportable services. Documentation for the encounter should include a statement of total time and the activities performed that contributed to that time. Total time on the date of the encounter is by calendar date, not a 24-hour period, unless a continuous service spans two calendar dates.
Medical Decision Making
Medical Decision Making (MDM) has four (4) levels defined in CPT: straightforward, low, moderate and high.
MDM includes establishing diagnosis, assessing the status of a condition, and/or selecting a management option. MDM is defined by three (3) elements. The elements are:
- The number and complexity of problem(s) addressed during the encounter.
- The amount and/or complexity of the data to be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management.
MDM Guidelines and CPT Definition Revisions
- CPT’s 99221-99222-99223 are used to report the first hospital inpatient or observation status encounter with the patient and reported when the patient has not received any prior professional services from the provider or another provider in the same group practice during the stay.
- CPT’s 99231-99232-99233 are used to report any inpatient or observation care encounter. Both of these code ranges are reported once per day.
- Each of these CPTs have had definition revisions to include reference to the new MDM guidelines and the minimum time requirements for each service.
Initial Inpatient & Subsequent Care Encounters: Updated Definitions
Following are the updated definitions for the initial inpatient and subsequent care encounters:
- 99221 – Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level MDM. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
- 99222 – Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
- 99223 – Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of MDM. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
- 99231 – Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level MDM. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
- 99232 – Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
- 99233 – Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of MDM. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.
Consultation CPT Code Revisions
There have also been revisions to the remaining consultation CPT codes.
Reminder: a consultation is a type of E/M service provided at the request of another physician or qualified health care provider to recommend care for a specific condition or problem.
A ‘consultation request’ for a patient or family is not reported using the consultation codes. The CPT code descriptions for these services have also been revised to reflect the new E/M guidelines.
- 99242 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward MDM. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
- 99243 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low MDM. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
- 99244 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate MDM. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
- 99245 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high MDM. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
- 99252 – Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward MDM. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
- 99253 – Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low MDM. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
- 99254 – Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate MDM. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
- 99255 – Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high MDM. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded.
Conclusion
While CMS policy will utilize the new CPT guidelines to determine the level of service, there will be minor variations in coding and reporting. CMS continues their rule of only one (1) E/M code to be billed per calendar date which means all E/M services on a single calendar date should be evaluated and a single code assigned to reflect the combination of these services. There are also changes in the use of the prolonged service codes for Medicare patients. CMS proposed additional HCPCS codes for each different family of E/M services. Additional information will be provided as the rules are finalized for 2023.
Mary Horkey
RCCIR, RCC, MSN-ARC
MSN Senior Coding Manager
Mary Horkey is a Radiology Certified Coder in Interventional Radiology (RCCIR) and a Radiology Certified Coder (RCC). She is a Senior Coding Manager with MSN Healthcare Solutions, with a special emphasis in education and training.
This educational guide was prepared as a tool to provide education for documentation and coding. It is not intended to affect clinical treatment patterns. The material provided is for informational purposes only. Efforts have been made to ensure the information within this document was accurate on the date of distribution. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT® codes, descriptions and other data are copyright of the American Medical Association (or such other date of publication of CPT®).All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Proprietary and confidential document. All rights reserved. No part of this document may be reproduced or used in any manner without the written permission of MSN Healthcare Solutions, LLC.
