Professional Documents
Culture Documents
CPT 2023 Updates
CPT 2023 Updates
Management Updates
(AMA Updates)
Padmaja Chilaka CPC,CPMA
2023 E/M
Guidelines
Disclaimer
This presentation is designed to offer basic information for
coding and billing. The information presented here is based
on the experience, training and interpretation of the author.
Although the information has been carefully researched and
checked for accuracy and completeness, the instructor does
not accept any responsibility or liability with regard to errors,
omissions, misuse or misinterpretation. This material is
intended as an Educational guide and should not be
considered a legal/consulting opinion.
Evaluation and Management
E VA L U AT I O N A N D M A N A G E M E N T C O D I N G , T O D AY A N D T O M O R R O W
1997-2010
1992 1995 July 1, 2022
Refining of
AMA created CMS Published AMA finalized 2023
Guidelines (2000
E/M codes Calculations E/M revisions
proposal rejected)
Nov. 1, 2019
1994 1997
CMS Revision of
CMS finalized 2021 office
Marshfield and other outpatient
Calculations
Clinic Beta Tool E/M revisions
(implementation
1/1/2021)
Deleted & Revision Codes
Evaluation and Management Categories for face-to-face encounter with the patient
and/or family:
•Office or Other Outpatient Services
•For 99211, the face-to-face services may be performed by clinical staff
•Hospital Inpatient and Observation Care Services
•Consultations
•Emergency Department Services
•For 99281, the face-to-face services may be performed by clinical staff
•Nursing Facility Services
•Home or Residence Services
•Prolonged Service With or Without Direct Patient Contact on the Date of an
Evaluation and Management Service
Deleted & Revision Codes
Deleted Additions/Revisions
99217 - OBS Discharge 99238, 99239
99218 - 99220 - Initial OBS 99221 - 99223
99224 - 99226: Subsequent OBS 99231 - 99233
99241 & 99251: Outpatient & Inpat Consultations 99242
99318: Nursing Facility Service 99307 - 99310
99324 - 99328: Domiciliary, rest Home, Custodial New Patient 99341, 99342, 99334 , 99345
99334 - 99337: Domiciliary, rest Home, Custodial Est Patient 99347 - 99350
99339 - 99340: Domicilliary, rest Home, Home Care CPO 99437, 99491, 99424, 99425
99343: Home or Residence Services 99341 - 99345
99356 - 99357: Prolonged Service Inpatient pr OBS 993X0
New & Established Patient
New Vs Established
Coders and providers are required to choose E/M visit levels based on either:
Medical Decision Making (using the new office/OP revisions MDM table) or
Total time spent on the day of the visit (using the new time ranges)
Problem
MDM
Risk Data
MDM
Medically Medically
Appropriate Appropriate
History Exam
Medical Decision Making
Chief Complaint – Reason for the visit
Brief
statement,
usually in the
patients own the
words, that Concise
statement reason(s)
describes the
describing for the
reason the
patient is seeing encounter.
the physician.
Number/Complexity of Problems Addressed – Problem Minimal
Minimal
•A problem that may not require the presence of a provider, but the service is provided
under the provider’s supervision
Self-limiting or Minor Problem
•A problem that is temporary and runs a definite prescribed course, is temporary in
nature, and is not likely to permanently affect the patient’s health status
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care:
Low
❑2 or more self-limited or minor problems;
Or
❑1 stable, chronic illness Or
❑1 acute, uncomplicated illness or injury
Or
❑1 stable acute illness Or
❑1 acute, uncomplicated illness or injury requiring hospital
inpatient or observation level of care.
Number/Complexity of Problems Addressed – Problem Moderate
Chronic Illness with Exacerbation, Progression, or Side Effects of Treatment
Number/Complexity of Problems Addressed – Problem Moderate
Elements of Medical Decision Making
Number and Complexity of Problems Addressed
at the Encounter
Moderate
Acute or Chronic Illness or Injury that Poses a Threat to Life or Bodily Function
•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
Elements of Medical Decision Making
Number and Complexity of Problems Addressed at the Encounter
High
❑1 or more chronic illnesses with severe
exacerbation, progression, or side
effects of treatment;
Or
❑1 acute or chronic illness or injury that
poses a threat to life or bodily function
Number/Complexity of Problems Addressed
Question Answer
Can point of care tests that are results Yes, these simple tests that do not
only—such as dipstick UA, quick strep require separate interpretation can now
and CBC—be counted as ordered or be counted as order/review as part of
reviewed for selecting an MDM level Data in MDM, even if the test was
even if the CPT code is billed for those reported by the physician/QHP
tests? performing the office E/M
If a test does not require separate interpretation (e.g., results only tests) AND
• Is analyzed as part of the MDM
• Counts as 1 item towards ordered/reviewed in Data
Amount/Complexity of Data Reviewed & Analyzed
Data Complexity
Question Answer
Question Answer
Analyzed: Analyzed is a term describing the process of using the data as part of the MDM. The data
element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought
processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the
results are reported. Therefore, when they are ordered during an encounter, they are counted in that
encounter. Tests that are ordered outside of an encounter may be counted in the encounter where
they are analyzed. In the case of a recurring order, each new result may be counted in the encounter at
which it is analyzed.
For example, an encounter that includes an order for monthly prothrombin times would count for one
prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent
encounter, may be counted as a single test in that subsequent encounter. Any service for which the
professional component is separately reported by the physician or other qualified health care
professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or
independently interpreted for the purposes of determining the level of MDM
Analysing Clarified
Amount/Complexity of Data Reviewed & Analyzed
Data Complexity
• A combination of different data elements, for example, a combination of notes reviewed, tests ordered,
tests reviewed, or independent historian, allows these elements to be summed. It does not require each
item type or category to be represented. A unique test ordered, plus a note reviewed and an
independent historian would be a combination of three elements.
• Of course, an interpreter should not be considered an independent historian as they are simply
relaying information presented by the patient.
Amount/Complexity of Data Reviewed & Analyzed
A form of interpretation should be documented but need not conform to the usual standards of a complete report
for the test.
Amount/Complexity of Data Reviewed & Analyzed
Amount/Complexity of Data Reviewed & Analyzed
Chief Complaint: Est Patient here for follow-up Diabetes and Hypertension Patient
presents today for his 6-month follow-up to review his Type 2 DM and
Hypertension. His DM has been controlled on Metformin for 2 years. His HTN is controlled
with metoprolol, started 6 months ago. Patient checks BS and B/P daily and reports WNL. No
other s/s to report today.
CMP and HbA1C lab tests ordered.
B/P 130/80 EKG performed today, normal sinus rhythm.
Patients' wife states he had an abnormal diabetic eye exam recently but can not remember
what the ophthalmologist said. The report is not in the chart. I spoke with Dr. Smith
(ophthalmologist) and he advised that he saw some mild changes in the retina and has arranged
to follow up with the patient.
Amount/Complexity of Data Reviewed & Analyzed - Example
E X A M PL E
• Counseling
• Diet and Exercise
• EKGs and EEGs
• Rest
• Superficial bandages and
Minimal - dressings
• Urinalysis
Risk • Ultrasounds, Echocardiogram
Risk factors are those that are relevant to the patient and procedure.
Risk of Complication and/or Morbidity or Mortality of Patient MGT
Chest x-rays,
CT/MRI w/o contrast
IV fluids w/o additives
Lab tests requiring
Low - Risk venipuncture
Minor surgery w/o risk factors
Over the counter drugs
Therapies (PT/OT, etc.)
Risk factors are those that are relevant to the patient and procedure.
Risk of Complication and/or Morbidity or Mortality of Patient MGT
Risk factors are those that are relevant to the patient and procedure.
Risk of Complication and/or Morbidity or Mortality of Patient MGT
Risk factors are those that are relevant to the patient and procedure.
Drug Therapy with Intensive Monitoring for Toxicity
A therapeutic agent which has the potential to cause serious morbidity or death
Monitoring should follow practice that is generally accepted for the drug but may
be patient specific in some cases.
If a provider considers a
treatment but chooses to
The 2021 guidelines make it Patient non-compliance not select that treatment,
clear that options (Z91.19) may add to risk, documentation should
considered, but not providers should document support the reason why,
selected. how. such as patient refusal,
patient is not a surgical
candidate, etc.
And
And /or
/or
Auditing Based on Time
15 m inutes
99202 99212 If < M
15-29 mins 10-19 mins use MD
99203 99213
30-44 mins 20-29 mins
99204 99214
45-59 mins 30-39 mins
99205 99215
60-74 mins 40-54 mins
Prolonged Services
h a n ges
C
2023 ming CMS
Co
Total time is the sum of all time, with and without direct patient contact and including prolonged
time, spent by the reporting practitioner on the date of service of the visit.
Use code 993X0 to report prolonged total time provided by the physician or GXXX3
QHP on the date of an inpatient (Nursing Facility, Observation or IP Consultation) E/M service, contact
beyond the required time of the primary service when the primary service level has been selected using
total time, each 15 minutes of total:
list separately in addition to CPT® codes 99223, 99233, 99236, 99255, 99306, 99310
Do not report 993X0 for any time unit less than 15 min
Do not report 993X0 on the same date of service as 90833, 90836, 90838, 99358, 99359)
For prolonged services on a date other than the date of a face-to-face evaluation and
management encounter with the patient and/or family/caregiver, see 99358, 99359.
*
Total time is the sum of all time, with and without direct patient contact and
including prolonged time, spent by the reporting practitioner on the date of
service of the visit.
Prolonged Services – 99358 & 99359 Codes
Total Duration of Prolonged Code(s)
Code(s) Services without Codes 99358 and 99359 are used when a
direct face-to-face Contact
prolonged service in relation to a face-to-face
Less than 30 minutes Not reported separately evaluation and management encounter with the
30-74 minutes 99358 X 1 patient and/or family/caregiver is provided on a
75-104 minutes 99358 X 1 and 99359 x 1 date other than the date of the E/M, whether
105 or more minutes 99358 x 1 and 99358 x 2 or time was used to select the level of the face-to-
more for each additional 30 face service.
minutes
Code Description Prolonged service without direct patient contact may only
be reported when it occurs on a date other than the date
99358 Prolonged evaluation and management
service before and/or after direct patient of the evaluation and management service.
care; first hour For example, extensive record review may relate to a
previous evaluation and management service performed
+99359 Prolonged evaluation and management at an earlier date.
service before and/or after direct patient However, it must relate to a service or patient which (face-
care; each additional 30 minutes. to-face) patient care has occurred or will occur and relate
to ongoing patient management.
Prolonged Services
Code Description
99415 First hour
+99416 each additional 30 minutes
Prolonged Service – Clinical Staff
The starting point for 99415 is 30 minutes beyond the typical clinical staff time for ongoing assessment of
the patient during the office visit. The Reporting Prolonged Clinical Staff Timetable provides the typical
clinical staff times for the office or other outpatient primary codes, the range of time beyond the clinical
staff time for which 99415 may be reported, and the starting point at which 99416 may be reported.
Place of Service – Initial Hospital OR Observation
The following codes are used to report the first hospital inpatient (21) or observation (22)
status encounter with the patient.
Initial hospital inpatient or observation care, per day, for the evaluation and management
of a patient, which requires a medically appropriate history and/or examination and MDM
Same Day
Admit/DC History & Exam MDM Time*
• The hospital inpatient (21) and observation (22) discharge day management codes are
used to report the total time (does not need to be continuous) spent by the physician or
QHP who is responsible for discharge services, on the day of the final discharge of the
patient.
• The codes include, as appropriate, final examination of the patient, discussion of the
hospital stay, instructions for continuing care to all relevant caregivers, and preparation of
discharge records, prescriptions, and referral forms.
If a consultation is performed in anticipation of, or related to, an admission by another physician or other QHP, and
then the same consultant performs an encounter once the patient is admitted by the other physician or other QHP,
report the consultant’s inpatient encounter with the appropriate subsequent care code (99231, 99232, 99233).
• These codes should also be used to report evaluation and management services
provided to a patient in nursing facilities (32), skill nursing facilities (31), a
psychiatric residential treatment center (56) and immediate care facility for
individuals with intellectual disabilities (54).
• Regulations pertaining to the care of nursing facility residents govern the nature
and minimum frequency of assessments and visits. These regulations also
govern who may perform the initial comprehensive visit.
• Modifiers may be required to identify the principal physician from specialist
performing consultations or concurrent care.
Initial History & Exam MDM Time*
Medical Appropriate History and/or
99304 examination Straightforward or Low 35
The following codes are used to report evaluation and management services
provided in a home or residence to an established patient.
(99334, 99335, 99336, 99337 have been deleted. For domiciliary, rest home [eg,
boarding home], or custodial care services, established patient, see home or
residence services codes 99347, 99348, 99349, 99350)
These codes are also used when the residence is an assisted living facility (13), group
home (14) (that is not licensed as an intermediate care facility for individuals with
intellectual disabilities), custodial care facility (33), or residential substance abuse
treatment facility (55).
Code Description Time
99347 MDM of straightforward complexity 20
99348 MDM of low complexity 30
99349 MDM of moderate complexity 40
99350 MDM of high complexity 60
Prolonged (99417) 75 minutes or longer
References
• AMA E/M 2023:
• https://onlinexperiences.com/scripts/Server.nxp?LASCmd=AI:1;F:LBSATTACH!V&AttachmentKey=8655664
• CPT® Evaluation and Management (E/M) Code and Guideline Changes https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
• New office and other Outpatient 2021 MDM Table https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
• AMA Guide for 2021 E/M Changes https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf https://
www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1
• CMS E/M Services Guide https://www.cms.gov/outreach-and-
education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
• MLN on Final Rules
https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-11-06-ASC-Presentation.pdf https://
www.cms.gov/files/document/12120-pfs-final-rule.pdf
• https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-2
• Medicare Claims Processing Manual Ch 12 https://www.cms.gov/Regulations-and-
guidance/GuidancE/Manuals/Downloads/clm104c12.pdf