AMA Announces Big Changes in 2023 to Remaining Evaluation & Management Coding

In 2019, the American Medical Association (AMA) published changes to the Evaluation and Management (E/M) codes and guidelines effective as of January 1, 2021. With that release of information, we had almost 3 years to adequately prepare for changes to a coding category that had not seen significant changes for almost 30 years. Last month, the AMA published the codes and coding guideline changes that we have been anticipating. These new changes will affect the following E/M guidelines and categories: 

• E/M Introductory Guidelines
• Hospital Observation Services
• Hospital Inpatient and Observation Care Services
• Consultations
• Emergency Department Services
• Nursing Facility Services
• Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services
• Home or Residence Services
• Prolonged Services

In an effort to remove obstacles that interfere with patient care, the AMA has mirrored many of the helpful changes made in 2021 to E/M Office/Other Outpatient Services (99202-99215), and applied them to the above-listed categories for a full revision of the E/M services.

Review of the 2023 E/M Changes

Scoring Criterion for E/M Services

As was done with the changes in 2021, Current Procedural Terminology (CPT) has eliminated the scoring of history and examination as part of E/M leveling. While similar to the many questions asked in 2021, this does not mean providers do not need to document a history or physical exam, they only need to document those data points that are relevant to the needs of the specific patient. Previously, we saw some providers performing portions of an exam just so they could reach the same level of medical decision making (MDM). But with this change, that conundrum simply goes away and providers can concentrate on their patient’s needs and care, and not on counting data points for history and examination that simply are not needed for every patient. 

In 2023, scoring for these new E/M categories will be determined by one of these two options:

• Two of the three elements of MDM
  • Number and complexity of problems addressed at the encounter
  • Amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications and/or morbidity or mortality of patient management
• Time
  • Total time on the date of the encounter, determined by adding together the face-to-face time with the patient and/or family or caregiver and non-face-to-face time personally spent by the physician or another qualified health care professional (QHP) on the day of the encounter (not including clinical staff time)*
    • *This does not include the time spent performing a separately reported service.

Deletion of Duplicative Straightforward MDM Consultation Codes

Just as 99201 was deleted due to its duplicative description of a straightforward MDM code that matched 99202 in 2023, the following consultation codes have been deleted as they have a duplicitous MDM level of work associated with another code in the same category: 

• Outpatient consultation code, 99241 has a straightforward MDM, as does 99242 so 99241 has been deleted.
• Inpatient consultation code, 99251, has a straightforward MDM, as does 99252, so 99251 has been deleted.

Coding guidelines associated with reporting consultation codes are unchanged other than they may be determined based on MDM or Time, and new Time thresholds have been published and these times are different for outpatient and inpatient.

Deletion of Observation Care Services Codes 

While observation care services are considered relevant and important to determining the length of stay a patient may undergo for the condition for which they are being evaluated, the AMA described them as duplicitous or redundant for coding purposes. They stated providers are already performing the same work that is required for inpatient initial/subsequent E/M services as they do for Observation Services, so they should utilize the same set of codes for reporting observation care services as they do for inpatient services. The changes made to these services include the following:

• Observation Discharge Care Services (99217)
  • Report instead 99238, 99239
  • Admit/Discharge on same date report 99234-99236
• Initial Observation Care Services (99218-99220)
  • Report instead 99221-99223
• Subsequent Observation Care (99224-99226)
  • Report instead with 99231-99233

Initial Hospital Inpatient and Observation Care Services - NEW

This new category merges inpatient and observation care services and makes them reportable with codes 99221-99223 and 99231-99233, based on scoring for either MDM or Time. The Time thresholds have also changed and the guidelines now provide a clarification of time specific to how these codes are reported: 

• Count the total time by calendar date of the encounter.
• A continuous service, spanning two calendar dates, is considered a single service.
• An encounter that starts prior to midnight and is continuous through midnight to the next morning, may have all that time applied to the reported date of service.
• Time thresholds have changed for inpatient/observation care services as follows:
  • 99221 (40 mins), 99222 (55 mins), 99223 (75 mins)
  • 99231 (25 mins), 99232 (35 mins), 99233 (50 mins)

Another big change, regarding these services the AMA announced, is that the old rule that bundled a provider’s service performed in the office or other location into the admitting E/M service, is no longer the rule. Now, providers who perform an E/M service outside the hospital, and during that service determine the patient should be admitted, may report that E/M service separately and not bundle it into the admitting E/M service. We will need to wait and see what the proposed rule has to say about this change. 

Emergency Department Services Code Changes

Due to the wide and varied way provider time is spent with patients in the Emergency Department (ED), time is not an appropriate factor to use in considering the level of E/M service for this category. Additionally, while 99281 and 99282 both have a straightforward medical decision making (MDM), the AMA decided to revise the code description for 99281 so it can be used for an ED service that does not require the presence of a physician/QHP, such as nursing care where maybe staples or sutures are removed, or for certain types of wound care services often performed by nursing staff under the supervision of the ED provider. 

The new levels of ED services may take a bit of getting used to, but for the sake of consistency, the following changes should reduce coding burden significantly: 

• 99281 E/M service that may not require a MD/QHP (previously a straightforward MDM)
• 99282 Straightforward MDM
• 99283 Low level complexity MDM
• 99284 Moderate level complexity MDM
• 99285 High level complexity MDM

Nursing and Skilled Nursing Facility Services

All nursing facility (NF) and skilled nursing facility (SNF) services will be reported with initial (99304-99306) or subsequent (99307-99309) nursing facility care codes, and will be determined based on the documentation of MDM or Time. New threshold times have also been assigned to each code. Remember the rule where a physician caring for the patient in an office setting determines they need to be admitted and then cannot bill for both the admission service and the E/M service? Well, under these new guidelines, these services are no longer considered bundled (by CPT guidelines) and can be separately billed. Whether Medicare and other payers decided to adhere to that change will be something we'll have to keep an eye out for. 

Discharge management services are used to report the initial (99315) service of 30 minutes (or less) of total Time  spent with the patient and/or family/caregiver (face-to-face is required), and if the documented Time exceeds the initial 30 minutes, more than 30 minutes may be reported with code 99316. 

Code Deletion: Annual nursing facility assessment code 99318 has been deleted and should be reported with subsequent nursing facility care services codes (99307-99310) or the appropriate HCPCS G-code for Medicare beneficiaries and those payers that follow Medicare guidelines. To report the nursing assessment, use the subsequent nursing facility care services codes (99307-99310), or if Medicare develops a G-code for reporting this service, use that for those payers who follow Medicare guidelines.

A new, high-level MDM type has been identified for initial nursing facility care performed by either the principal physician/QHP, referred to as, “Multiple morbidities requiring intensive management,” which can be found on page 31 of the AMA’s “CPT® Evaluation and Management (E/M) Code and Guideline Changes” for 2023.” Additionally, be sure to carefully review the changes to the guidelines for reporting consultations and specialist services when performed by a physician/QHP other than the principal physician.

Deletion of E/M Category Domiciliary, Rest Home, or Custodial Care Services 

The following category of E/M services and codes have been deleted and categorized under a new E/M Category called Home or Residence Services. 

• Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services (99324-99337) will be reported with codes from the new E/M Category Home and Residence Services.
• Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home Care Plan Oversight Services (99339-99340) will be reported with Care Management or Principal Care Management codes. 

Home and Residence Services

This category defines a home as, “a private residence, temporary lodging, or short-term accommodation” and provides additional details and residence types in the definition. Don’t forget that intermediate care facilities are considered nursing facilities and require reporting with the nursing facility services codes instead of Home and Residence Services codes. 

This category is divided into new (99341-99345) and established (99347-99350) services and also follow the coding guideline of coding based on the level of MDM or Time. 

Prolonged Services

Many of the prolonged services codes have also been deleted to allow a simplified form of prolonged coding, like we saw in 2021, with a single prolonged E/M code for office/outpatient services (99417). Currently, a new code is being created to report prolonged services for inpatient, observation, and nursing facility prolonged services (993X0 - the X in this code is temporary), will be the surprise code published in the new CPT codebook. This new code will then make prolonged services reporting simple by having one code (99417) for office/outpatient prolonged services and another (993X0) for inpatient, observation, and nursing facility prolonged services. 

As for now, hopefully this summary of changes will help you prepare for 2023 and the changes that will take place across the E/M services categories. Don’t forget, these changes will not become effective until January 1, 2023, so stick to the current 2022 codes and guidelines until the new year. 

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