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Resolved E/M Updates

Looking for more info on the E/M table of risk?

What are the levels of risk?

Find out more here.

Risk is determined by referring to the table of risk below which describes four levels of medical jeopardy:

1. Minimal Risk

This is the lowest level of risk possible. It is required for benign encounters such as a level 1 new office patient (99201) or a level 2 office visit with established patient (99202).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

  • One self-limited or minor problem (e.g., insect bite, cold)
Diagnostic Procedure(s)

  • Lab tests
  • Chest X-ray
  • EKG/EEG
  • Urinalysis
  • Ultrasound/Echocardiography
  • KOH prep
Management Options Selected

  • Rest
  • Gargles
  • Elastic bandages
  • Superficial dressings
2. Low Risk

This is the second lowest level of risk. Although marginally more serious than Minimal Risk encounters, Low Risk patients are generally quite healthy. Many physicians are surprised to learn that this is the level of risk required for the so-called “routine” level 3 office follow-up visit (99213).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

  • Two or more self-limited or minor problems
  • One stable chronic illness
  • Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)
Diagnostic Procedure(s)

  • Physiologic tests not under stress (e.g., PFTs)
  • Non-cardiovascular imaging studies with contrast (e.g., barium enema)
  • Superficial needle biopsies
  • ABGs
  • Skin biopsies
Management Options Selected

  • Over-the-counter drugs
  • Minor surgery with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids without additives
3. Moderate Risk

This is the second highest level of risk. However, a cursory review of the qualifications for this level of medical jeopardy reveals that these patients are usually not very sick. This is the level of risk required for a level 2 hospital progress note (99232) or a level 4 office follow-up visit (99214).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

  • One or more chronic illness with mild exacerbation or progression
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
  • Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis
  • Acute complicated injury (e.g., head injury with brief loss of consciousness)
Diagnostic Procedure(s)

  • Physiologic tests under stress (e.g., cardiac stress test)
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsies
  • Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)
Management Options Selected

  • Minor surgery with identified risk factors
  • Elective major surgery with no risk factors
  • Prescriptions drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocations without manipulation
4. High Risk

This is the highest level of risk. This level of risk is required for a level 3 admission H&P (99223), a level 5 office follow-up visit (99215) and a level 3 hospital progress note (99233) .

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

  • One or more chronic illness with severe exacerbation or progression
  • Acute or chronic illness or injuries which pose a threat to life or bodily function (e.g.,
    multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive
    severe rheumatoid arthritis, psychiatric illness with potential threat to self or others,
    peritonitis, acute renal failure)
Diagnostic Procedure(s)

  • Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac EP testing
  • Diagnostic endoscopies with identified risk factors
  • Discography
Management Options Selected

    • Elective major surgery with identified risk factors
    • Emergency major surgery
    • Parenteral controlled substances
    • Drug therapy requiring intensive monitoring for toxicity
      Decision not to resuscitate or to de-escalate care because of poor prognosis



 
AMA releases E/M guidelines for 2023.

CPT® Evaluation and Management (E/M)
Code and Guideline Changes
This document includes the following CPT E/M changes,
effective January 1, 2023:
• E/M Introductory Guidelines related to Hospital Inpatient and Observation
Care Services codes 99221-99223, 99231-99239, Consultations codes 99242-
99245, 99252-99255, Emergency Department Services codes 99281-99285,
Nursing Facility Services codes 99304-99310, 99315, 99316, Home or
Residence Services codes 99341, 99342, 99344, 99345, 99347-99350
• Deletion of Hospital Observation Services E/M codes 99217-99220
• Revision of Hospital Inpatient and Observation Care Services E/M codes
99221-99223, 99231-99239 and guidelines
• Deletion of Consultations E/M codes 99241 and 99251
• Revision of Consultations E/M codes 99242-99245, 99252-99255 and
guidelines
• Revision of Emergency Department Services E/M codes 99281-99285 and
guidelines
• Deletion of Nursing Facility Services E/M code 99318
• Revision of Nursing Facility Services E/M codes 99304-99310, 99315, 99316
and guidelines
• Deletion of Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care
Services E/M codes 99324-99238, 99334-99337, 99339, 99340
• Deletion of Home or Residence Services E/M code 99343
• Revision of Home or Residence Services E/M codes 99341, 99342, 99344,
99345, 99347-99350 and guidelines
• Deletion of Prolonged Services E/M codes 99354-99357
• Revision of guidelines for Prolonged Services E/M codes 99358, 99359,
99415, 99416
• Revision of Prolonged Services E/M code 99417 and guidelines
• Establishment of Prolonged Services E/M code 993X0 and guidelines

://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
 
All E/M codes will be selected on MDM or Time.

These major changes are going to spread to the hospital, skilled nursing facility, and home visits.

2023 high-level points from the newly revised CPT E&M guidelines:

  • The definition of new and established has not changed.
  • Services reported separately cannot be double-dipped in Medical Decision Making (MDM). For example, if a provider bills for an echocardiogram, they may (and should) document the results in their note, but they can’t take credit for the echo in their MDM calculation for the E&M visit.
  • There are no longer mandatory elements of the history or physical examination (PE).
    • History and PE should be done as “medically appropriate.” I think Social History (SH – do you smoke, drink, or do drugs?) is always relevant and appropriate. Mandatory review of systems is eliminated.
    • H&P may not be required for billing, but they are still critical to determining medical necessity of actions and very important medicolegally.
  • MDM
    • There are four levels of MDM: straightforward, low, moderate, and high.
    • Three elements are assessed as to the level of complexity, and the level is determined by best two out of three.
      • Number and complexity of problem/s that are addressed during the encounter
        • Problems have specific definitions laid out (e.g., stable/exacerbated, chronic/acute, complicated/uncomplicated).
        • The problem must be addressed to be counted regardless of how you want to determine that (e.g., MEAT, TAMPER). Not just in a problem list. Not delegated to the consultant for complete management.
        • It isn’t only the final diagnosis; the presenting signs/symptoms may drive this element.
      • The amount and/or complexity of data to be reviewed and analyzed
        • Although they get the point at time of ordering, the review and analysis are expected and inherent to the order.
        • Obtaining additional or corroborative history from an independent source increases complexity.
        • This is a good time to reinforce that data should be interpreted, not just copy and pasted, not just “The X-ray looked good to me.” Don’t need a formal report but need “independent interpretation” to accrue these points.
      • Risk of complications and/or morbidity or mortality of patient management
        • If management options were considered and discussed but not undertaken, this increases risk, but only if your provider documents the process.
        • Social Determinants of Health (SDoH) are considered moderate risk if they “significantly limit diagnosis or treatment,” so your providers should consider creating a macro explicitly saying this.
        • Drug therapy requiring intensive monitoring for toxicity is high risk. This is not monitoring for therapeutic efficacy but assessing for toxic adverse effects.
        • Parenteral controlled substances has been added to high risk. This was not originally found in the Office/Outpatient matrix.
icd10monitor.com

The 2023 Physician Fee Schedule Proposed Rule: All E&M Is Going to MDM or Time

Editor’s Note: The unofficial, unpublished FY 2023 Physician Fee Schedule Proposed Rule (CMS-1770-P) was posted on July 7, 2022. Comments will be taken at
icd10monitor.com icd10monitor.com
 
Want to get a head start on 2023 E/M?
Listen to this free webinar from AMA.

AMA recorded their webinar on Evaluation and Management (E/M) CPT® code descriptors and guidelines for 2023. Download a PDF of the presentation slides and watch on demand to understand:
  • How the 2021 office visit revisions laid the groundwork for the 2023 E/M updates
  • What is changing in 2023 for the remaining E/M codes that used History/Exam/MDM, including:
    • E/M introductory guidelines
    • Inpatient and observation care services
    • Consultations
    • Emergency department services
    • Nursing facility services
    • Home and residence services
    • Prolonged services
Screen Shot 2022-08-16 at 8.25.08 AM.webp
 
The revisions to the E/M categories themselves & the criteria for E/M level assigned will change to reduce administrative burden and decrease unnecessary documentation not needed for patient care.

The level of service is based on medical decision-making or total time as the sole criterion for the level of service.

The three elements to the levels of Medical Decision Making (MDM) include the following:

  1. The number and complexity of problem(s) that are addressed during the encounter
  2. The amount and/or complexity of data to be reviewed and analyzed.
  3. The risk of complications and/or morbidity or mortality of patient management

The E/M categories that will undergo revision in 2023 include the following:

  • Inpatient and observation care services
  • Consultations – both outpatient and inpatient
  • Emergency department services
  • Nursing facility services
  • Home and residence services
  • Prolonged services
Hospital Inpatient and Hospital Observation Services

Beginning Jan. 1, 2023, the changes will be effective:

  • Hospital Observation Services categories and E/M codes will be deleted
    • E/M codes 99217, 99218-99220 and 99224-99226
  • Hospital Inpatient services categories and E/M codes have been revised and titled:
  • Hospital Inpatient and Observation Care Services
  • E/M codes 99221-99223, 99231-99233 and 99238, 99239
  • Observation or IP care Services including admit and discharge on same date are retained
    • E/M codes 99234-99236
Read more here:
icd10monitor.com

2023 E&M Revisions Warrant Study to Prevent Denials

Colleen Deighan and ICD10monitor are producing an editorial series to report on the updated changes from the AMA. EDITOR’S NOTE: This morning, Colleen
icd10monitor.com icd10monitor.com
 
Get answers for these & more.

E/M visits for upcoming procedures.
If it's relative valued is it separately billable.
The decision for surgery after tests.

Read more here.
www.aapc.com

10 FAQs About E/M Guidelines and Coding

Industry experts explain the intricacies of the 2021 E/M guidelines. During the Evaluation and Management (E/M) Panel general session at AAPC's HEALTHCON Industry experts explain the intricacies of the 2021 E/M guidelines.
www.aapc.com www.aapc.com
 
CPT® Evaluation and Management (E/M) Code and Guideline Changes This document includes the following CPT E/M changes, effective January 1, 2023:

• E/M Introductory Guidelines related to Hospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations codes 99242- 99245, 99252-99255, Emergency Department Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315, 99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-99350

• Deletion of Hospital Observation Services E/M codes 99217-99220

• Revision of Hospital Inpatient and Observation Care Services E/M codes 99221-99223, 99231-99239 and guidelines

• Deletion of Consultations E/M codes 99241 and 99251

• Revision of Consultations E/M codes 99242-99245, 99252-99255 and guidelines

• Revision of Emergency Department Services E/M codes 99281-99285 and guidelines

• Deletion of Nursing Facility Services E/M code 99318

• Revision of Nursing Facility Services E/M codes 99304-99310, 99315, 99316 and guidelines

• Deletion of Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services E/M codes 99324-99238, 99334-99337, 99339, 99340

• Deletion of Home or Residence Services E/M code 99343

• Revision of Home or Residence Services E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines

• Deletion of Prolonged Services E/M codes 99354-99357

• Revision of guidelines for Prolonged Services E/M codes 99358, 99359, 99415, 99416

• Revision of Prolonged Services E/M code 99417 and guidelines • Establishment of Prolonged Services E/M code 993X0 and guidelines

READ MORE HERE:
 

AMA E/M CPT learning module​

This educational module provides an overview of the evaluation and management (E/M) code revisions and shows how it differs from current coding requirements and terminology.

Learning Objectives
1. Explain the CPT E/M office or other outpatient services revisions and when changes took effect
2. Identify why CPT E/M revisions were needed and benefits provided
3. Describe how the foundational changes will impact your work

https://edhub.ama-assn.org/cpt-education/interactive/18057429
 
Coding E/M in 2023

AAPC Rae answers some questions.

See the questions & answers here:

www.aapc.com

Coding ED E/M in 2023

AAPC leadership answers your questions about the latest changes in the CPT® Emergency Department subsection. Attendees at AAPC’s AUDITCON, Nov. 3-4, 2022, Learn about the latest changes in the CPT® Emergency Department subsection.
www.aapc.com www.aapc.com
 
CMS.gov
Their evaluation and management (E/M) content is under revision and will be available soon. See
CY 2023 Medicare Physician Fee Schedule (PFS) rules for more E/M information.
Additional E/M Resources
● Evaluation & Management Visits | CMS
● MM12982 - Medicare Physician Fee Schedule Final Rule Summary: CY 2023 (cms.gov)
● 2023 ICD-10-CM | CMS
● 2023 ICD-10-PCS | CMS
● CPT® Books
● CPT® Evaluation and Management
● Evaluation and Management (E/M) Visit FAQs Physician Fee Schedule (PFS)
● HCPCS
● Medicare Benefit Policy Manual
● Medicare Claims Processing Manual
● Medicare Information for Patients
● Medicare Learning Network® (MLN) Products
If you’d like to receive the latest Medicare program information, please sign up for the weekly
MLN Connects® newsletter.

 

E&M Codes Appended with Modifier 25​

Effective on February 1, 2023, many providers will change how we reimburse for non-preventive E&M services appended with Modifier 25 billed on the same date of service as procedure codes that have a global surgical period of 0 or 10 days for services rendered on February 1, 2023, and after. Many Payers will reduce the reimbursement by 50% for the service with the lower relative value unit (RVU) or the provider’s submitted charges if less. They will no longer reimburse for the practice expense component twice (once in the E&M and once in the global day code). Procedures with a 90-day global surgical period will not be included.

The following E&M codes are included when appropriately appended with modifier 25:

  • 99202 – 99205
  • 99212 – 99215

The following services are excluded from the policy:​

  • All E&M codes related to preventive and administration services
  • Emergency Room E&M codes: 99281 – 99285
  • Procedures having a 90-day global surgical period will not be included in this policy.
Commercial plans affected:

  • Horizon fully insured commercial plans
  • Braven Health℠ Medicare Advantage plans (participating providers only)
  • Administrative Services Only group employer plans, including the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP)
  • Federal Employee Plan

Policy Update: E&M Codes Appended with Modifier 25 Effective February 1, 2023 - Horizon Blue Cross Blue Shield of New Jersey

To ensure our members remain our priority, we continually review our products, networks and policies. As part of this review, we look at industry best practices and benchmarks to help us understand if an adjustment to a reimbursement approach is necessary to help reduce wasteful spending.
www.horizonblue.com www.horizonblue.com
 
CPT® defines the risk of complications and/or morbidity or mortality of patient management/treatment at an encounter as “management and treatment” risk. This is distinct from the level of risk for the “condition of presenting problem(s)” or the “number and complexity of the problem(s) to be addressed” (NCOPA). Therefore, there are two drivers of risk to the patient: management/treatment risk and condition risk.

See the accurate coding highlights of how the coding process can be achieved using any order/two of the following three MDM elements:

1. Complexity of the problems to be addressed – what kind of problem(s) is being presented?

2. Amount/complexity of data – this is merely a check-off system. Was it done or not? This section also drives the risk complexity of management and treatment. How much was done for the problem(s) addressed?

3. Risk – All risk is tied into the presenting problem(s)/condition risk and how they are managed and treated – management/treatment risk.


www.aapc.com

Comparing 2023 E/M MDM and Table of Risk

Side by side, the 1995 and 1997 Documentation Guidelines and the 2023 CPT® E/M Services Guidelines aren’t so different. Some hospitals and coding and Side by side, the 1995 and 1997 Documentation Guidelines and the 2023 CPT® E/M Services Guidelines aren’t so different.
www.aapc.com www.aapc.com
 

Comparison of 2023 E/M MDM Grid and Risk Table​

The tables below show the exact same information, except that which was added to the 2023 MDM grid for low MDM (highlighted).

E/M needs two of the following three MDM elements:

1. Complexity of the problems to be addressed – what kind of problem(s) is being presented? (Chief Complaint)

2. Amount/complexity of data – what was actually documented. This section also drives the risk complexity of management and treatment. What was done for the problem(s) addressed?

3. Risk – All risk is tied to the presenting problem(s)/condition risk and how they are managed and treated – management/treatment = risk.

Low comparisons:

Screen Shot 2023-07-10 at 1.54.52 PM.webp
Screen Shot 2023-07-10 at 1.55.04 PM.webp

Moderate comparisons:

Screen Shot 2023-07-10 at 1.55.37 PM.webp
Screen Shot 2023-07-10 at 1.56.02 PM.webpScreen Shot 2023-07-10 at 1.56.24 PM.webp
www.aapc.com

Comparing 2023 E/M MDM and Table of Risk

Side by side, the 1995 and 1997 Documentation Guidelines and the 2023 CPT® E/M Services Guidelines aren’t so different. Some hospitals and coding and Side by side, the 1995 and 1997 Documentation Guidelines and the 2023 CPT® E/M Services Guidelines aren’t so different.
www.aapc.com www.aapc.com
 

2023 E/M Audit Worksheet from AAPC​

E-BRIEF
Ensure your team is accurately coding the new E/M Guidelines with our updated 2023 E/M Audit Worksheet. Designed to make your coding team more efficient and accurate, this quick reference guide features the specific elements and content that auditors look for. Download the FREE tool today and enjoy access to:
  • MDM Definitions
  • MDM Risk Table
  • Calculation Guide
  • Time-Based Coding Guidelines
  • E/M Code Tables
  • And more!

Get a free copy for download here:
www.aapc.com

E/M Audit Tool eBrief

AAPC here to help you understand how to improve business results. From RCM to educational excellence, we offer a wide range of solutions to meet your needs.
www.aapc.com www.aapc.com
 
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