2023 Evaluation and Management Coding Changes – Part 2

With so many coding changes just around the corner, it’s hard to keep up – we’re here to help! Check out this high-level overview of some of the Evaluation and Management (E/M) coding changes starting in 2023.

Change is never easy, but the overarching goal of these changes is to improve the quality of current and future care. Not a bad reminder to keep in mind as we cover some of these new updates!

Who do 2023 E/M guidelines apply to?

These new E/M guidelines apply to a significant portion of healthcare professionals, so it’s important to review the list and determine if you or your organization fall under these categories. Additional categories could be added in the years to come.

• • 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 direct patient contact on date of an E/M service

What factors should be considered when selecting the level based on medical decision making (MDM)?

These provide an overview of some of the criteria, but this is not a comprehensive list. However, these are many of the items noted as important in the upcoming changes.

• • The number and complexity of problems  
  • Comorbidities are only considered if they address and impact the MDM  
  • Amount/complexity of the data reviewed and analyzed
  • This does not include translation services
  • The history must be obtained directly from the historian

What factors should be considered when selecting the level based on time?

This can be a complex guideline to follow, as it requires a very nuanced and detailed approach to time-based level selections.

• • Face-to-face service is a requirement
  • Time spent by clinical staff is not included
  • Use 99211 if the clinical staff performs a face-to-face​ evaluation
  • Use 99281 for clinical staff performing face-to-face evaluations in the emergency department
  • Do not include time spent analyzing separately reportable procedures

What are the considerations in shared or split services?

This update requires a new level of coordination between healthcare professionals. For example, if a physician and nurse practitioner are discussing a patient, only one of those providers can bill for that time.   

• • Services should only include distinct time that is reportable  
  • These items should not be included in minutes:
  • Time spent on separately reportable services
  • Travel time
  • Any teaching not specific to the management of a patient

What are the requirements for billing a new patient (otherwise established)?

While there aren’t any new criteria, here are some important reminders to keep in mind when multiple providers are treating a patient.

• • Professional services​ are defined as face-to-face​ services by a provider who may report E/M services)
  • The criteria for a new patient is an individual who has not received any professional services from any provider in the group practice for the exact same specialty and subspecialty within the past three years.
  • On-call or covering providers should bill patient encounters as if the patient was seen the provider who is not available
  • When NP or PA are working with physician, they are considered exact same specialty and subspecialty

What are the requirements for billing initial services (otherwise subsequent)?

These requirements for initial vs. subsequent have not changed, but it’s critical to be mindful of the criteria below. A reminder never hurts!

• • Initial services are defined as professional services​ (face-to-face) from a provider to a patient who has NOT been seen by another provider from the same practice group of the exact same specialty and subspecialty during observation, admission, and stay
  • Subsequent services are for patients who HAVE been seen by a provider in the group for the exact same specialty and subspecialty during observation, admission, and stay
  • The on-call or covering provider must bill the service as if they were the provider who is not available
  • When a patient transitions between facilities or areas, it should be billed as one service​
  • Observation to inpatient ​are considered the same stay
  • Skilled nursing facility to nursing facility are considered the same stay​

What are the requirements for Hospital Inpatient and Observation?

Heads up – these codes are changing in 2023!

Take a look at these new criteria and familiarize yourself with new billing and coding changes.

• • When a patient is admitted after a same-day encounter at another site, the original E/M is separately reportable with modifier 25​
  • If the first site was a consultation, the consulting provider should bill the subsequent facility
  • The consultation rule applies to same day and the previous day​
  • The consultation rule applies even if the first encounter was billed with an office visit​
  • Discharge codes should include all services for that date, even if they are not consecutive

What are the requirements for consultations?

A consultation must be requested by another provider or an appropriate source (e.g., a non-clinical social worker, insurance company, educator, or attorney). Please review the additional consultation requirements below.

• • If the patient requested a second opinion, it is not considered a consultation​
  • A report must be created for the requestor
  • The provider may initiate treatment during the consultation visit. ​If the consultant continues care, follow-up visits will be billed with subsequent codes
  • One consultation per inpatient stay​
  • There is no difference for new or established​ patients
  • There are separate codes for outpatient and inpatient encounters

Looking for more information on 2023 coding changes? We’ve got a webinar for that! Watch the webinar for a deeper dive into additional changes and codes.

Did you miss part 1 of this blog series? Read it here.