Understanding the Changes to the 2023 Evaluation & Management (E/M) Definitions for Chronic Conditions

November 15th, 2022 - Aimee Wilcox
Categories:   Audits/Auditing   Diagnosis Coding  

Changes to the 2023 E/M Diagnosis Definitions for the Chronic Problems 

If you report Evaluation and Management (E/M) services you are likely well aware of the major changes that occurred in 2021, which facilitated selecting the level of service based on scoring medical decision making (MDM) or time. Changes at that time were only made to the codes in the E/M category of Office or Other Outpatient E/M services (99202-99215). Now in 2023, the remaining E/M categories are undergoing very similar changes. 

One major change in 2021, was the addition of definitions to clarify specific MDM terminology; however, due to confusion surrounding some of these definitions, an additional update was made in April of 2021 to provide further clarity. Now, with the changes to the other E/M categories, new terminology is being introduced and therefore the definitions have undergone continued changes. Those definitions specific to the first element of MDM (number and complexity of problems addressed), are the definitions this article will be addressing. 

In 2021 there were eight levels of complexity associated with diagnoses, but in 2023, two additional levels of complexity have been provided. These two correlate with the changes to E/M services in the inpatient facility setting. For ease of understanding and comparison, we have grouped acute definitions together in a previous article (click HERE to review that article) and the diagnosis definitions for chronic conditions in this article. 

Of note, simple removal of any examples provided in the 2021 examples is a common theme in the 2023 E/M guideline changes. 

Chronic vs Acute Illness

While the guidelines do not define the timeframe of when an acute illness becomes a chronic illness, they do provide a definition of a chronic illness, which is

"A problem with an expected duration of at least one year or until the death of the patient."

Additionally, whenever a provider documents a condition as chronic, it is considered chronic and the same goes for when they document a condition as being acute.

Diagnosis Definitions for Chronic Illnesses or Injuries

According to the CPT E/M guidelines, there are four chronic diagnosis definitions:

  1. Stable, chronic illness
  2. Chronic illness with exacerbation, progression, or side effects of treatment
  3. Chronic illness with severe exacerbation, progression, or side effects of treatment
  4. Acute or chronic illness or injury that poses a threat to life or bodily function

There were no additional definitions provided; however, all of the definitions underwent changes, which we will review here: 

  1. Stable, chronic illness: The following bullet points describe a stable chronic illness:
    • Expected duration of one year or until the patient's death
    • Considered chronic even if the stage or severity does not change
    • If not at treatment goal, then condition is not considered stable
    • Risk of morbidity without treatment, is significant

For the 2023 updates, the following sentence was removed, as is a common theme among these 2023 definition updates:

“Examples may include well-controlled hypertension, non-insulin-dependent diabetes, cataract, or benign prostatic hyperplasia.”

The only other change to this diagnosis definition was to emphasize the last few words of the definition by making it a new sentence, as follows:

"For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant."

Taking a closer look at a few examples, 

  • Consider a patient with chronic hypertension, currently treated with oral medications and recommended lifestyle changes, returns for a follow-up evaluation and presents with no significant improvement in blood pressure readings, even after consistently taking the prescribed medications and making the recommended lifestyle changes (chronic, unstable)
  • Now consider a patient with chronic hypertension, currently treated with oral medications and recommended lifestyle changes who returns for a follow-up evaluation and presents with improved blood pressures that have reached the provider-recommended target goals. The provider makes no changes in the medications and asks the patient to return in six months for another follow-up and has them continue what they are doing with the taking medications and continuing with the lifestyle changes (chronic, stable)

Now for an example that is a little more difficult,

"The patient with chronic hypertension returns for a six-month follow-up. The provider documents in the history of present illness, "Hypertension is stable on current medications. While improvements have been made, I'd like to see even more by reaching a goal of 120/80 mmHg. To accomplish this treatment goal we will increase her medication by 5 mg twice daily, and see her back in one month to see how she is doing." (chronic, unstable)

Providers sometimes use language that sounds like a patient's condition is stable but in reality if they are changing up the medications and changing the treatment goal to reach a better outcome, the condition is not stable and should not be reported as if it is. Consider submitting a provider query for clarification, as needed.

2. Chronic illness with exacerbation, progression, or side effects of treatment: The following underlined portion of this chronic diagnosis condition has been removed for the 2023 updates:

"A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care."

The following bullet points summarize this diagnosis definition:

  • A chronic illness (lasting up to a year or until the death of the patient)
  • Unstable (not controlled or at treatment goal)
  • Could be exacerbated (worsening) or even progressing to the next stage
  • The provider is making changes and treatment recommendations to try and bring the illness under control
    • Could include medication changes or current medication dose increases
    • Could require the assistance of therapy, occupational, physical, speech, or referral to a specialist

3. Chronic illness with severe exacerbation, progression, or side effects of treatment:

The 2023 update to this definition has changed just slightly from this:

"The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care"

to this,

"The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care."

This change is explained by the addition of hospital-level diagnosis definitions due to the major changes associated with inpatient hospital admissions and observation E/M guideline changes. Of note, notice that the only difference between this definition and the one before it, is the word, "severe." To qualify for this level of diagnosis definition, the documentation should provide details about why the provider feels this is a severely exacerbated chronic illness. What are the complicating factors that changed it from just an exacerbated chronic illness to one that is severely exacerbated? Or, how is it severely progressing, or what were the side effects of treatment that were so severe, the encounter required an escalated level of care, and possibly hospitalization?

4. Acute or chronic illness or injury that poses a threat to life or bodily function: The bolded and underlined text is the new definition:

"An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity."

What changed? They added the two sentences noted above (underline and italics added), but removed the examples from the 2021 definitions, noted below:

"Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status."

When an illness or injury (acute or chronic), is so bad that the patient may lose their life or the functionality of an organ system or body part, without treatment, the documentation really needs to include details that make it obvious as to what and why the patient could die without treatment for or the documented risks to bodily function. Without these complicating factors and details about the threat to the patient's life or functionality, the service would not be supported.

As a review, chronic conditions fall into one of four categories: 

  1. Stable, chronic illness
  2. Chronic illness with exacerbation, progression, or side effects of treatment
  3. Chronic illness with severe exacerbation, progression, or side effects of treatment
  4. Acute or chronic illness or injury that poses a threat to life or bodily function

 

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Questions, comments?

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