E/M Transformations and Clarifications Eff January, 1 2023

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jan 10th, 2023

The changes keep coming, but change can be a good thing as long as we pay attention. Look out for new code description changes when coding E/M in 2023. Several codes have been consolidated, revised, or deleted. In fact, CMS states, “In total, the E/M code sets being revised for 2023 comprise approximately 20 percent of all allowed charges under the Medicare Physician Payment Schedule. Therefore, these changes are estimated to require a reduction of about 1.5 percent to the 2023 Medicare conversion factor due to statutory budget neutrality requirements.” 

This change affects payments, fee schedules, and guidelines, as well as other coding changes we will address in this article.  

Clarification
The revised 2023 E/M guidelines clarify the codes that may be used by physicians and QHPs other than the ED staff, “These guidelines are for services that require a face-to-face encounter with the patient and/or family/caregiver. (For 99211 and 99281, the face-to-face services may be performed by clinical staff.).”

Description Changes
In the example below, CPT code 99304 no longer has the three required components of History, Exam, and MDM.

Effective Jan. 1, 2023, office visits, hospital, and nursing facilities coding is now based solely on medical decision-making (MDM) or total time. The only exception is for emergency department visits, which must be coded based on MDM, and hospital discharge visits, which must be coded based on time.

Some changes, as in the code below for nursing facilities, only require “a medically appropriate history and/or examination and straightforward or low level of medical decision making."

Note: A medically appropriate history or exam is still required. To make record-keeping simple for providers, we no longer have to count the number of components on the ROS (review of systems). Starting January 2023, these components are no longer required to select the code level. Before 2023, we had to include the HPI - History of present Illness, ROS Review of systems, i.e., Eyes, ears, nose, resp... and the PFSH - Past, Family, and Social History. The exam is still required but only what is medically necessary for the visit. For example, if a patient sees a podiatrist,  the provider does not have to examine and document they looked at your ears and eyes; they can examine what they feel is medically appropriate. In other words, the requirements for determining the code level have been removed, not the entire exam.

Nursing Facility
Nursing facilities, formerly called skilled nursing facilities (SNFs), intermediate care facilities (ICFs), or long-term care facilities (LTCFs), are all under one category; Nursing Facility Services, the AMA calls them nursing facilities and skilled nursing facilities.

• The history and physical examination requirements have been eliminated for coding nursing home visits.
• When selecting a level of MDM, the number and complexity of problems addressed during the encounter is considered.
• There are two subcategories of nursing facility services: Initial and Subsequent Nursing Facility Care.
• Both subcategories apply to new or established patients.
• Modifiers may be required to identify the role of the individual performing the service, such as the AI Modifier- “Principal physician of record” or other appropriate modifiers to identify other providers furnishing specialty care.
• The annual exam CPT code 99318 is now coded as subsequent nursing home visits, reported with 99307-99310. 
  
  

Hospital Inpatient and Observation Services

• Observation codes are no longer being used in 2023 as they have been merged into the initial, subsequent, and discharge codes (Deleted 99217-99220, 99224-99226).
• There is only one set of codes now used for both inpatient and observation.
• The history and physical examination requirements have been eliminated (Note: Medically appropriate history and physical are still required; however, it is no longer used when selecting the code level).

Consultations

• Consultation codes 99241-99251 have been deleted to align with the four levels of MDM.
• The definition “Transfer of Care” has been deleted from the guidelines.
• Code revisions to code descriptors 99242-99245, 99252-99255, and guidelines. 

Emergency Department Services

• Time is not considered when selecting a level of service.
• Emergency Department visits are not defined as new or established patients.
• 99281 has a description change “Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.”
• Critical care may be reported in addition to ED service for clinical change.
• Guidelines define the practice by physicians and QHPs other than ED staff only.

Deleted Codes and replacement Codes in 2023