2023 CPT  Evaluation and Management (E/M) coding changes and guidelines

2023 CPT Evaluation and Management (E/M) coding: The E/M guidelines have sections that are common to all E/M categories and sections that are category specific For 99211 and 99281, the face-to-face services may be performed by clinical staff.)

These E/M guidelines are written for the following categories:

■ Office or Other Outpatient Services

■ Hospital Inpatient and Observation Care Services

■ Consultations

■ Emergency Department Services

■ Nursing Facility Services

■ Home or Residence Services

■ Prolonged Service With or Without

2023 CPT Evaluation and Management (E/M) coding

What is New Patient?

 

A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years

What is established Patient?

An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years

What is emergency department patient?

No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

What is Initial services?

An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.

What is Subsequent Services?

A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stay.

Services Reported Separately:

·         Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately.

·         The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service

·         The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code

·         The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended

Can we consider History and/or Examination for level of E/M Services 2023?

The extent of history and physical examination is not an element in selection of the level of these E/M service codes

2023 CPT Evaluation and Management (E/M) coding

2023 medical decision making changes

Select the appropriate level of E/M services based on the following:

 1. The level of the MDM as defined for each service, or

 2. The total time for E/M services performed on the date of the encounter.

Within each category or subcategory of E/M service based on MDM or time, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories or subcategories of service.

Guidelines for Selecting Level of Service Based on Medical Decision Making:

 

What are the Four types of MDM 

1.       Straightforward

2.       Low

3.       Moderate

4.       High

 The concept of the level of MDM does not apply to 99211, 99281

Three elements of MDM

To select the level of an E/M service, two of the three elements of medical decision making must be met or exceeded

1. Problem: The number and complexity of problems addressed.
2. Data: Amount and/or complexity of data to be reviewed and analyzed.
3. Risk: Risk of complications and/or morbidity or mortality of patient management