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Are you prepared to discover the 2023 CPT® E/M changes? The CPT® book’s Evaluation and Management (E/M) section has undergone a considerable overhaul. 25 codes will no longer be used. The introductory instructions have been updated to reflect changes to five separate code groups. Services that last a long time are getting yet another update. The American Medical Association’s E/M revisions are discussed in this article, but Medicare’s proposed acceptance of these codes and policies is not mentioned. This will be covered in a subsequent article.

These are the codes that will be removed.

  • Codes for hospital observation services (99217–99220, 99224–99926)
  • Codes for consultation 99241, 99251
  • 99318 Nursing facility service
  • Services for domiciliary care, rest homes (like boarding homes), or custodial care, 99324–99328, 99334–99337, 99339, or 99340
  • Code for resident or home services 99343
  • Codes for prolonged services 99354–99357

Initial as well as follow-up services

There is a new component named initial and subsequent services for hospital inpatient, observation care, and nursing facility codes. It holds true for both brand-new and returning patient visits. The AMA asserts:

“For the purpose of differentiating between initial or later visits, professional services are defined as those face-to-face services provided by physicians and other trained health care professionals who may report assessment and management services. During the patient’s admission and stay in an inpatient, observation, or nursing facility, an initial service is one that the patient has not previously received from the doctor, another qualified health care professional, or another doctor or other qualified health care professional who belongs to the same group practice.” [1]

  • These codes are used by doctors and other certified medical professionals with emergency and medical care as part of their scope of practice.
  • It outlines the requirements for doctors and other licensed healthcare workers who perform in the same group practice and belong to the same specialization and subspecialty. The organization may only bill one initial service during an inpatient, observation, or nursing facility stay, and follow-up services are billed with subsequent visits. This is different from the way groups are reporting observation or inpatient services. When partners are filling in for one another, the practitioner who provides the initial service is responsible for billing for that service. On subsequent days, the fill-in physician reports a subsequent visit. It adheres to the Medicare requirement that doctors in the same group who practice the same specialty should be paid and billed jointly.

Choosing a service level based on 2023 CPT® E/M adjustments

According to the plan, the AMA has expanded the framework for office and outpatient visit code selection to include the remaining E/M services that were determined by history, exam, medical judgment, or time. 

By 2021, this framework will be in place.

The change impacts the following services:

  • Services for hospital inpatients and observers (One set of codes will utilized for both observation and inpatient care.)
  • Advisory services
  • Hospital emergency services (Time should not be a consideration when Choosing an ED visit)
  • Hospital nursing services
  • House or home services

Time or medical judgment may determine the level of E/M service for the aforementioned code groups. (Time does not affect the decision to visit the ED.) The number and complexity of issues that must be resolved during the encounter, the volume and/or complexity of data that must be reviewed and analyzed, and the likelihood of complications, morbidity, or death associated with patient care are all factors that must be considered when selecting a code. This page provides an overview of the 2023 CPT® E/M Changes. On Doctor Papers, more resources go over choosing the level of service. Those resources will be updated to reflect the modifications made by the AMA to their discussion of medical decision-making.

Services for hospital inpatients and observers

Since the observation codes 99217–99220 and 99224–99226 have been eliminated; the same codes will be used to report services for both inpatients and patients under observation. Two sets of codes exist. When a patient is admitted and discharged on the same day of the year, one group is used, 99234–99236. The second set is for patients whose stay exceeds one calendar day. For the initial service, dial 99221–99223; for following visits, dial 99231–99233; and for discharge services, dial 99238 and 99239.

When the prerequisites for consultation are satisfied, according to CPT®, a consulting physician may report codes 99252–99255 in an inpatient environment. So naturally, Medicare no longer accepts these codes, and many private insurance companies have stopped doing so.

The CPT® reiterates in the recommendations for this part that advanced practice nurses and physician assistants are regarded as practicing in the same specialty and subspecialty as physicians when they collaborate with them. Therefore, the AMA has also modified its recommendations for admitting a patient from another facility of care. Although it is unlikely that Medicare or other parties will abide by this advice, the AMA recommends it.

When the patient is admitted as an inpatient or placed on observation status at the hospital during an encounter at a different site of service, “the services at the initial site can be reported separately” (like a hospital emergency room, office, or nursing home). To indicate a significant, individually identifiable service was performed on the same date by the same doctor or other qualified health care professional, modifier 25 may be added to the other assessment and management service. [2]

The AMA adds that changing from inpatient to observation or from observation to inpatient does not count as a new stay for a patient. That is, if the patient’s status changes, only bill for an additional initial service.

The same day of the week for both admission and discharge

Whether the patient is an inpatient or receiving observation-level treatment, the codes 99234–99236 are used for hospital inpatient or observation care and contain the admission and discharge on the same day. 

According to CPT, there must be two encounters—admission and discharge—in order to report these services. Therefore, the patient should be mentioned twice in the record. In addition, although CMS acknowledges and pays for these services, a patient must stay in the facility for more than eight hours in order to report them. Although not a CPT rule, this is nevertheless CMS policy.

What codes to use when the patient was and wasn’t at the facility for at least eight hours was laid forth in a table in the Physician Final Rule. Below is a copy of the table with the explanations of the CMS rules replaced with a column for CPT rules and codes.

 

Table the updated 2023 CPT® EM changes (1)

 

What impact do the 2023 CPT® E/M changes have on the reporting of consultation codes?

There will no longer be a need for the two low-level consult codes, 99241 and 99251. The comments in this section have been significantly reduced from the book published in 2022. CPT® clarifies two points that most people will recognize. Consultations must be requested by someone other than the patient’s family, lawyer, or non-clinical social worker. And the consultant’s opinion and any treatments ordered or done must be communicated in writing to the seeking physician or other competent healthcare professional. CPT® recommends using codes 99242–99245 for services provided in the office or different outpatient environments, such as the home or the emergency department. The codes 99252-99255 are used in hospital inpatients, observation level patients, nursing facility residents, and patients in a partial hospital setting. A consult is only utilized once per specialist and group per stay.

There must be a documented report and a request for consultation from another medical expert or other relevant sources. Both of these should be documented in the consult note. The idea of transfer of care has been eliminated from the 2023 CPT book and is no longer used to evaluate consults.

Medicare has no plans to alter its policies, and the program does not acknowledge the use of these codes.

Department of emergency services

Patients who visit the ED are neither new nor ongoing patients. In 2023, employ medical decision-making to determine the level of service. In ED visits, time is not an issue. The descriptor for code 99281 has changed. It is now described as a “visit to the emergency room for a patient’s evaluation and care, which may or may not require the presence of a doctor or other trained health care provider.” As a result, it is similar to code 99211, which does not necessitate the presence of a physician or other competent healthcare practitioner. On the other hand, a medical practice is not permitted to submit a claim under 99281 for services carried out by a nurse the hospital employs, and Medicare does not permit incident-to-service claims to be submitted. Therefore, it’s tough to imagine a medical group reporting 99281.

Hospital nursing services

The patients in nursing homes, skilled nursing institutions, psychiatric residential treatment facilities, and facilities providing immediate care for people with intellectual disabilities utilize the codes in this area. In the 2022 book, the editorial remarks have undergone considerable revision. According to the AMA, the admitting physician and clinician in charge of managing the patient’s treatment are the principal physicians. Other doctors and licensed healthcare workers may also see the patient.

It’s possible that “modifiers will be needed to identify the function of the person providing the service.” [3]

Even though this information isn’t included in the CPT® book, I’m going to presume that the modifiers in question are HCPCS modifiers and that they identify the attending physician, an AI, a nurse practitioner, or a physician assistant as the one who performed the service.

According to the AMA, the primary physician or another qualified healthcare practitioner must make a high-level medical decision for first-level nursing facility care. This relates to the component of the interaction that deals with the volume and complexity of issues raised. It is:

“Numerous morbidities require rigorous management”: A group of ailments, syndromes, or functional limitations likely to call for frequent drug adjustments, additions to other treatments, and re-evaluations. As a result, the patient faces a serious risk of deteriorating medical (and behavioral) conditions as well as the risk of hospital (re)admission.

The criteria for how much data must be evaluated and processed, how complicated it must be, and how likely it is that patient management may result in problems, morbidity, or mortality remain the same.◄”[4]

In other words, the AMA is adopting a specific definition regarding the quantity and degree of complexity of issues handled for initial nursing facility services. However, remember that the other two components of the first nursing facility services remain the same.

Regardless of the length of stay, the AMA states that the initial nursing facility services may be utilized once per admission by a doctor or another certified healthcare practitioner. According to the AMA, a doctor must do an initial thorough visit in a skilled nursing facility in accordance with Medicare regulations. According to the AMA, if permitted by state law or regulation, trained healthcare practitioners may report the initial comprehensive nursing facility visit in a nursing facility (the distinction is not made in a skilled nursing facility).

According to the CPT® book, initial services provided by doctors and other competent healthcare providers who are not the patient’s admitting or primary physician may be documented with initial nursing facility or consultation codes.

The two discharge services for nursing facilities, 99315 and 99316, are time-based codes. They comprise the time spent on the day the doctor or other licensed healthcare provider sees a patient in person. Therefore, even if the patient’s discharge from the facility isn’t that day, you should still report the service on the day the practitioner visits the patient.

Services provided in homes or residences

The domiciliary, nursing facility, or custodial care services codes have been removed. Instead, use the home or residence service codes to report services provided to patients in those settings. These are codes 99341, 99342, 99344, and 99345 for new patients. Code 99343 is no longer in effect. Services for new patients or residents are offered at four different levels. There are four home or residence service levels for established patients, denoted by the codes 99347-99350. According to the AMA, you cannot add travel time when choosing a code based on time.

The 2023 CPT® E/M adjustments pay close attention to prolonged care codes

CPT® is eliminating extended codes 99354, 99355, 99366, and 99357. These codes for prolonged face-to-face care could be used in conjunction with inpatient, observation, or nursing facility codes and office/outpatient codes. When services are rendered on a date other than a face-to-face visit, CPT® will continue to accept the non-face-to-face prolonged care codes 99358 and 99359. There is an extended range of services for which CPT® advises against including the duration of non-face-to-face long care when you’re reporting these other care management services. These services may not be reported on the same day, and you may never double-count the time spent. By designating the codes 99358 and 99359 as invalid, which would prevent Medicare patients from being reimbursed for them, CMS is proposing to change their status indication.

CPT® has updated the editorial remarks for the protracted clinical staff codes 99415 and 99416. Additionally, Medicare does not pay for these codes.

In 2023, outpatient consult code 99245, home visit codes 99345 and 99350, and cognitive evaluation code 99483 will be reported along with the existing prolonged care code 99417, which may presently only be used with codes 99205 and 99215.

The AMA is drafting an updated code for extended care, but it will not be included in the document’s July release. Instead, the AMA is employing the placeholder code 993X0 for extra 15-minute blocks of time with or without patient interaction to be used with hospital codes 99223, 99233, and 99236, as well as consult code 99255, nursing facility codes 99306 and 99310. The extended services codes can only be used with the category or subcategory’s top-level code. You won’t be surprised that Medicare is creating new HCPCS codes for prolonged care and will no longer accept CPT® codes in the proposed regulation.

In addition to its July recommendation, the AMA is currently working on a new code for extended care. The AMA is employing the placeholder code 993X0 for extra 15-minute blocks of time with or without patient interaction to be used with hospital codes 99223, 99233, and 99236, as well as consult code 99255, nursing facility codes 99306 and 99310. The extended service codes can only be used with the category or subcategory’s top-level code. You won’t be surprised that Medicare is creating new HCPCS codes for prolonged care and will no longer accept CPT® codes in the proposed regulation.

This is a summary of the E/M modifications that the AMA announced in July 2022 and became effective on January 1, 2023. Do you currently wish you had more information? The information on Doctor Papers will continue to be updated. However, you could print out the AMA advice and study it while holding your 2022 CPT® book. I took that action. You can see what changes have been made to the included areas. The first footnote of this article has a link to the AMA paper. Join us for our August webinar if you’re interested in learning more about what CMS suggests.

The 2023 Proposed Physician Rule’s policy recommendations will be discussed in the 2023 CMS Proposed Physician Rule webinar. Participants will have the following options following the session:

  • The deadline for comments and the final regulation should be specified.
  • List the policy changes that will impact their practices throughout the coming year.

References

Nicoletti, B. (2022, July 18). 2023 CPT E/M Changes. 

CPT® Evaluation and Management (E/M). (n.d.) Retrieved on July 5, 2022,

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