Everything You Need to Know About the 2023 E/M Guidelines

Hi, everybody. In today’s podcast, we’re going to talk about the new 2023 guidelines for evaluation and management codes and how they might impact your providers and your practice. But first, Welcome to the Revenue Cycle Decoded Podcast. My name is Gena Cornett and I help medical practice managers like you get the revenue cycle edge in your practice. I am passionate about helping you learn the skills you need to be a revenue cycle hero, advance your career, and improve your financial results.

Let’s dive right in to the 2023 changes to the E/M guidelines. In 2021, AMA released changes to the guidelines for coding office and other outpatient evaluation and management services. The guidelines were intended to reduce the administrative burden placed on physicians. But, because the guidelines were only changed for outpatient visits, physicians and other qualified healthcare providers were faced with managing two sets of guidelines if they saw patients in other settings such as inpatient, critical care, emergency department, or post-acute settings. Now, for 2023, AMA’s CPT® Editorial Panel has approved revisions to the rest of the E/M code section, which will include E/M services provided in these other settings.

According to the AMA, the revised guidelines include:

New descriptor times (where relevant).

Revised interpretive guidelines for levels of medical decision making.

Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services).

Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).

So to review the changes that will take place: Medical decision making or time will be used to level the E/M code for E/M codes that have levels of services. The provider must include a medically appropriate history and/or physical exam when performed, but the history and exam will not be used to determine the level, and the provider determines the nature and extent of the history and/or physical exam. This guideline brings the E/M codes for hospital inpatient and other settings in line with the guidelines for outpatient E/M leveling. This should, theoretically, lead to less time spent by the physician documenting history and exam and perhaps less cloning of information in the EMR, which is a practice the physician should avoid anyway, although with outpatient documentation in the specialty in which I practice, I have not seen a significant decrease in cloned or “pulled forward” information.

Within each category or subcategory of E/M service based on MDM or time, there are three to five levels of E/M services available, but you have to remember that you can’t interchange levels among different categories or subcategories. For example, a new patient outpatient E/M 99202 is not the same thing as an established patient outpatient E/M 99212 – you have to read and understand the definition for each level in each category or subcategory. And the concept of MDM does not apply to the outpatient visit code 99211, which is used most often for an incident-to nurse visit, or to 99281 which describes emergency department evaluation and management services that may not require the presence of a physician or qualified healthcare provider.

Medical decision making levels are either straightforward, low, moderate or high; and three elements define medical decision making:

The number and complexity of problem(s) that are addressed during the encounter;

The amount and/or complexity of data to be reviewed and analyzed;

The risk of complications and/or morbidity or mortality of patient management.

Let’s look at each of these elements:

The number and complexity of problems addressed is pretty straightforward. Keep in mind that just because the documentation includes a laundry list of problems, doesn’t mean all the problems were addressed. To get credit for this element, the physician must document that he or she actually made a medical decision or discussed the problem with the patient or family member. For example, if your patient presents with pain in the knee, just noting that the patient has COPD doesn’t give the physician credit for that problem. The physician would need to document that he or she addressed – in other words, evaluated or treated - the COPD in the encounter and that the COPD increased the amount and/or complexity of data to be reviewed and analyzed, or impacted the risk of complications, morbidity and/or mortality of the patient management decision. Just stating that another healthcare professional is managing the condition also does not give your provider credit for addressing the condition, nor does referral without evaluation or consideration of treatment. For your patients who are hospital inpatients or observation patients, the problem addressed is the problem being managed or co-managed by your provider on the date of the encounter, not necessarily the problem on admission.

The next element is the amount and/or complexity of data to be reviewed or analyzed. Data includes any medical records, tests, or other information that the physician must obtain, order, review and analyze for the encounter, including information obtained from multiple sources or interprofessional communications that are not reported separately, and interpretation of tests that are not reported separately. If the physician orders a test, the review of the test result is not counted separately at the next encounter. When tests are ordered during an encounter, they are counted during that encounter – and remember, you can only count a test in MDM if you will not be separately reporting the test. For recurring orders, like monthly prothrombin times, you would count each new result for the encounter in which it is analyzed. Panels are counted as a single test, and pulse oximetry is not considered a test that counts for MDM. If the provider is ordering serial tests during the same encounter, for example, multiple blood glucose tests, the test will only count once. Ordering a test can include those considered but not selected after shared decision-making, for example, if a test would normally be performed but due to risk the physician decides not to order the test for the patient. Remember, that the physician must document his or her medical decision making in this case. Each unique test, order, or document is counted to meet a threshold number. The data element includes review of materials from a unique source. A unique source is a physician or other qualified healthcare professional who is in a different group or a different specialty or subspecialty or is a unique entity, and review of all the materials from each unique source counts as one element. Receiving information from an independent historian, for example, a family member if the patient is a poor historian or unable to communicate, is counted in the data element, as is discussion of management or test interpretation with an external physician or other qualified healthcare professional or appropriate source, as long as you are not separately reporting the discussion with another code. Other appropriate sources could include other licensed practitioners, physicians, facilities or organizational providers such as hospitals, nursing homes, or home health care agencies. social workers, counselors, parole officers, teachers, case managers, lawyers, etc, but not family or informal caregivers. If the provider is including discussion with another healthcare professional in the data element, then a direct interactive exchange must be documented – that means, the exchange of information can’t be filtered through case managers or other persons, and sending chart notes or written exchanges doesn’t count.

The third element is the risk of complications and/or morbidity or mortality of patient management. This includes the management options the physician selects and those that are considered but not selected after shared decision making with the patient or family. The physician should include a statement in the note regarding shared decision making by discussion the treatment options with the patient and/or family, discussing the patient and/or family’s preferences and providing education, and explaining the risks and benefits of the management options. If social determinants of health will impact the risk of complications or morbidity from the treatment decision, they should also be documented in the note. This is probably the trickiest element because, according to the AMA, “definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

To qualify for a particular level of MDM, two of the three elements for that level must be met or exceeded. AMA has created a table to help physicians and coders in selecting the correct level of MDM. In the same document, the AMA has provided a list of definitions to clarify the terms in the table. I will link to the guidelines where you can find this table and the definitions in the show notes.

Now, E/Ms can also be leveled using time. For outpatient visits beginning in 2021, and now for all face to face E/M services that include levels with the exception of emergency department services, it is no longer necessary that counseling and coordination of care make up 50% of the visit in order to count time. In the outpatient office, if the provider’s time is spent supervising clinical staff who perform the face-to-face services of the encounter, the guidelines instruct to use CPT code 99211.

Time is the total time on the date of the encounter and includes both face-to-face time with the patient and/or the family or caregiver, and non-face-to-face time which is personally spent by the provider on the day of the encounter performing activities which are typically performed by the provider – it doesn’t include time normally performed by your clinical staff or other separately reported activities. In the case of split visits between a physician and another qualified healthcare provider, time spent by each is summed to define total time.

AMA provides tables with the time ranges for each level, and as with the 2021 guidelines, provides prolonged services codes for reporting time that exceeds the maximum range and are included in the document linked in the show notes. As in 2021, CMS will provide its own prolonged service codes.

Other changes in the guidelines include deletion of the hospital observation services E/M codes 99217-99220; instead, observation services will be included in Initial hospital care (99221-99223), subsequent hospital care (99231-99233), observation or inpatient hospital care (99234-99236), and hospital discharge (99238-99239) codes.

Consultation E/M codes 99241 and 99251 will be deleted to align the four levels of MDM and consultations E/M codes 99242-99245, 99252-99255 and guidelines are revised to remove confusing definitions. The definition of “transfer of care” has been deleted.

Emergency department services EM codes 99281-9285 and guidelines are revised; note that time cannot be used to level emergency department E/M services.

Nursing facilities service E/M code 99318 is deleted and all other nursing facility E/M codes and guidelines are revised to reflect leveling based on medical decision making or time; Also note a new definition of “multiple morbidities requiring intensive management” is considered at the high-level MDM or initial nursing facility care.

Domiciliary, rest home, and custodial care services section is deleted and E/M codes 99324-99238, 99334-99337, 99339, 99340; and home or residence services E/M code 99343 are deleted. These services are merged with the existing home visit codes.

Home or residence service E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines are revised to reflect leveling based on medical decision making or time;

Prolonged services E/M codes 99345-99347 are deleted; these services will now be reported either with the office prolonged services code 99417 or with the new prolonged service E/M code 993X0 to be used with inpatient, observation and nursing facility services.

So, to sum up, if your physicians and providers work primarily in the outpatient world, they should already be familiar with the 2021 revised guidelines. I’ve found in my work that with the introduction of the new guidelines in 2021, E/M levels dipped temporarily as physicians and providers learned the new guidelines, but as they received education and their documentation of their medical decision making improved, E/M levels also improved. If your providers are seeing patients in the hospital or other settings, then the new guidelines should be welcome news. The new guidelines should make coding and billing of E/M services in your practice easier, especially if you have already implemented the 2021 guidelines. And they will mean that we will all be using one set of guidelines, rather than trying to manage and code for two different sets of guidelines. I have found that the 2021 guidelines for outpatient visits were much more intuitive and easier to teach to physicians and easier for physician to understand.

To be successful in implementing the 2023 E/M guideline changes, it will be important for practice managers and coders to read up on the new guidelines and put an education plan in place for your physicians. A great place to start is directing your physicians to AMA’s free online webinar on the changes which explains the changes, benefits, and how it will impact the provider’s work, and which I will link in the show notes.

I would love to hear your take on the new guidelines and how you feel they may impact your physicians and your practice.  You can find me on Facebook on the Revenue Cycle Decoded group or on LinkedIn on the Revenue Cycle for Medical Practice Managers Group.  You can join me in either place and let me know how you are educating your providers to the new guidelines.

I also want to you invite you to my free weekly webinar “Revenue Cycle 101 for the Medical Practice Manager” where we walk through the steps of the revenue cycle, talk about what can go wrong at each step, and I give you some practical actions you can take to improve your cash flow, days in A/R, and profitability. The webinar is held every Wednesday from 12 pm to 1 p.m. Eastern time, it’s a Lunch and Learn, or maybe Breakfast and Learn if you are on the West coast or mountain time. It’s a great webinar and I’m certain you will find it valuable. You can go to Revenuecycledecoded.com and find the link to sign up.

I'm also hosting a paid Front End Denials Decoded Workshop on August 14 from 1 p.m. - 3 p.m. EST.  This workshop will review denials and rejections that take place due to faulty processes in your front end revenue cycle and we won't just discuss the rejections and denials themselves, but also how to track and trend, how to perform a root cause analysis, and how to implement a performance improvement and prevention plan using a team approach.  This class is limited to 25 people.  You can again go to RevenueCycleDecoded.com to find the link and sign up.  The cost to attend is $147.

With that, I want to thank you for joining me on today’s podcast. I look forward to serving you on future podcasts. Until next time, make every day count!

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Resource: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Resource: https://edhub.ama-assn.org/cpt-education/interactive/18057429