2023 Evaluation & Management Updates Free Webinar

October 24th, 2022 - Aimee Wilcox

Categories: Evaluation & Management (E/M)

Congratulations on implementing the major Evaluation and Management (E/M) changes that became effective in 2021 for the Office and Other Outpatient E/M Services (99202-99215), a big transition for all provider organizations, and hopefully yours has experienced great success.

Now, it is time to transition the remaining E/M service categories to the same process. Last month we published an article on the upcoming E/M changes headed our way in 2023 (click here to access the article). While the changes are significant, they continue to follow the previously outlined changes seen in 2021, with scoring of an E/M service being determined by medical decision making (MDM) or total time, with the exception of the Emergency Department, which cannot use time as a scoring factor and must only score based on the level of MDM.

Medically Appropriate History and Examination

If you have ever coded a hospital record, you already know that often the interval history or history section in general, can be confusing. Often you cannot see a difference between the prior day’s documentation and the current day's documentation. By allowing providers to document a medically appropriate history and examination based on their professional opinion and need, along with no longer having to score those sections as part of the overall E/M leveling process, it will make big difference for coder, auditors and our providers, too.

Total Provider Time

Speaking of scoring based on time, what has your organization done to ensure time is properly captured in the medical record? Does your organization use a computer assisted coding (CAC) program? If so, then creating a section header using the right terms (e.g., Total Provider Time:) is extremely important to ensure the engine can first identify the section and, secondly, can capture the time. This helps distinguish provider time from clinical staff time as well - another important factor in correctly documenting in the medical record.

Medical Decision Making

With a reduction in the burden of documenting either the history or examination so they meet the level of medical necessity noted in the MDM section, providers can now concentrate more fully on documenting to support the patient’s true complexity and needs, in the MDM section. Providers can hopefully spend a little of that saved time documenting the status of a chronic or acute condition as stable, worsening, severe, or exacerbated.

Data should be formatted within the MDM section for clarity to make it easy to see what was ordered and performed during the encounter, what was reviewed from a prior encounter or different provider and if anything was discussed or physically reviewed again. What other medical professionals or family members did the provider speak with about the patient’s condition and care? Having this in a simple format makes it easy to score and easier to prove when faced with an audit.

And finally, how are your providers identifying the risk associated with the patient’s condition, treatment recommendations and/or failure to follow the recommended treatment? Are the medications being reviewed for these chronic conditions before refilling? Or are they just an afterthought?

Be Aware of the Overall 2023 Changes

The changes that are being implemented on January 1, 2023 are significant because they are for all remaining E/M categories, and not just one. We invite you to attend a free webinar on these 2023 Evaluation and Management changes to get a feel for what they are and how these categories and guidelines have been streamlined and changed.

Another important change that we should be aware of is the deletion of many prolonged E/M service codes to be replaced by a new inpatient prolonged service code. In 2021 we were introduced to 99417 , which is the prolonged service code specifically assigned to 99202-99215 , but this will also be eligible to be assigned to other outpatient services and a new inpatient code for all inpatient services. What a great way to streamline coding for ease of application!

For additional information on how get an early understanding of the changes headed your way, join us for our next webinar, "Webinar Title" scheduled for Thursday, Oct. 6, 2022 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.

Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s).

About the Author: Aimee Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. She believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.

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Comments

May 16th, 2023 - friesenrg

DATA

I realize these guidelines are to be used by the reporting physician or other qualified health care professional to select the appropriate level of service. These guidelines do not establish documentation requirements or standards of care. The main purpose of documentation is to support care of the patient by current and future health care team(s) YET can the coder/auditor utilize the physician's order as a DATA element i.e. BNP, CBC, CMP and chest x-ray ordered -- MODERATE level "or" does the provider need to have this documentation their specific encounter with the patient. In reviewing CMS, and the Medicare Integrity manual as well as documentation guidelines for Medicare services, I am not seeing whereas the order cannot be utilized. In my own opinion, since the E/M is based on the provider's documentation, then the data elements stating which lab was ordered and for what reason i.e. whether it be a S&S or a definitive diagnosis to see if there is an exacerbation should be documented in the encounter and not utilized just based on the physician's order in the EMR? Thank you in advance.

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