Significant Evaluation and Management Coding Changes Again on The Horizon

Author: By Jim Tudor, PCA, CPC Director of Coding & Billing Compliance

Sep 23, 2022 | Coding Compliance

In 2021, the American Medical Association implemented significant changes to the Evaluation and Management (E/M) code sets applicable in the office/outpatient setting. Those changes, which were intended to simplify coding by placing more emphasis on complexity and time, were not extended to other E/M service categories. At the time, many questioned whether the “old system” would remain in place, and if so, for how long. In response, the AMA hinted in a not-so-subtle way that 2021 was the tip of the iceberg, and that many more changes would be forthcoming. They did not disappoint.

In 2023, the CPT coding rules across several other E/M categories will be modified to ‘mirror’ many of the office/outpatient visit changes previously made. Additionally, in an attempt to further simplify code choices and minimize redundancies, several E/M code subsets will be deleted or significantly revised.

  1. The following observation codes will be deleted
    1. 99217-99220
    2. 99224-99226
  2. The following inpatient hospital codes will be revised to include services performed in the observation setting
    1. 99221-99223
    2. 99231-99233
    3. 99238-99239
  3. The domiciliary/assisted living and rest home codes 99324-99337 will be eliminated
    1. Providers will report services performed in those locations with the home visit codes 99341-99350
  4. Consultations (99242-99245, 99252-99255), often the subject of much confusion and misinterpretation, will include revised prefatory language aimed at clarifying the intent of these codes
  5. Level 1 consultations will no longer be a thing – quite literally – as 99241 and 99251 will be deleted in their entirety

The biggest change, which will apply universally to all problem-oriented E/M code levels, will be the elimination of requirements associated with the history and examination. Providers will have the option to report E/M visits based on the medical decision making (MDM) or time. The infrastructure of MDM will bear some resemblance to the previous system (see 1995 and 1997 E/M rules), however, the new construct is much more streamlined and intuitive. The time element will be expanded to capture most aspects of physician work performed outside direct patient contact on the same day as the face-to-face encounter, such as chart review, phone calls, coordinating care, family conferences, etc. These activities, in addition to time engaged in direct patient contact, will be reportable based on the cumulative time spent on the date of service by the physician/other qualified health practitioner (e.g., NP, PA).

The Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule indicates that CMS will honor “most” of the AMA changes, while leaving the door open for a future overlay of Medicare-specific rules if they become “necessary in future rulemaking”. This would not be unprecedented: CMS superimposed guidelines upon guidelines in 1995 (and again in 1997) to provide more granularity and definition to the E/M rules incepted by the AMA in 1992. Good to know that, for now at least, there will be uniformity.

Finally, the prolonged services codes were not left untouched: 99354-99355 and 99356-99357 will be deleted. For office/other outpatient visits, 99417 will be billable by units for each additional 15 minutes of time superseding the typical time threshold associated with the base E/M code. Although 99417 is not new, it will essentially replace 99354-99355 as the sole CPT code to be used for prolonged care. 99417 can only be billed in tandem with a level 5 office visit (99354-99355 could be billed together with any qualifying E/M level). For Medicare (and those who follow Medicare policy on prolonged care), a different code, G2212, must be used. And, just to keep things interesting, the clock starts ticking 15 minutes later than it does for 99417. On the hospital side, a new code will be created to replace 99356-99357 (prolonged service in the inpatient or observation settings), which has not been determined at the time of this publication.