Answers to Your Questions on 2023 Healthcare Coding Changes

Our 2023 Healthcare Coding Changes webinar raised a lot of questions, so we’re tackling your insightful inquiries! Our presenter, CJ Wolf, MD, reviewed and answered questions that popped up during the webinar, so check out all his answers below. You can also see a recording of the webinar too.

Question: Any ideas for dealing with/sorting out data elements that are copied/pasted in daily progress notes? We don't give credit when we can tell it’s a carry forward.

Answer: Organizations need to make some internal decisions and policies about these types of issues. It sounds like your organization may have done this. On the other hand, I am not aware of any regulation that states the method by which accurate and medically necessary information is entered in the medical record, so I am usually pretty careful about automatically dismissing something that is copied and pasted.    If the copied and pasted information is accurate and medically necessary for that particular encounter, then I don’t see why it can’t be copied and pasted. Saying it can’t be copied and pasted is essentially saying whoever entered data into the medical record must physically type information with a keyboard.  I do understand the risks and sloppiness that can occur from copied and pasted information. I think the key is the person responsible for making medical entry records must make sure the documentation is accurate, pertinent, and medically necessary for the given encounter.


Question: Can you please clarify a little on "decision regarding hospitalization or escalation of hospital level of care" in the risk section of MDM. If a patient is transferred from observation to inpatient status, would you consider this in that category? Or would you only consider scenarios when patient is moved from a regular bed to ICU to fit this category?

Answer: I would preface my answer by saying it will depend on reviewing the specific medical record for the encounter, while also considering medical necessity from a clinical standpoint, as well as any other official guidance given from CPT® or payors. With that said, the statement does have an “or” in it.  This seems to imply the scenario before the “or” and after the “or” both apply. The statement before the “or” reads “decision regarding hospitalization.” This seems to suggest a patient transferred from observation to inpatient status could fall into this category, assuming the hospitalization is medically necessary.


Question: Data regarding tests ordered/reviewed for inpatient can be complicated for scoring.  Would you recommend the inpatient provider document clearly what they order under A&P or in the case of a review of a test, they document the review and relevance?

Answer: When I provide education to providers, I encourage them to be as clear as possible as to what they are ordering and why. I also encourage them to document the review and relevance as you suggest. I do so because I know it is possible that others who might review the documentation will not be able to decipher rationale without some explanation. However, I also believe it is essential for coders and auditors to learn why a test might be ordered and reviewed and what the relevance might be in the event it is not clearly documented.

For example, in the CMS E/M document MLN006764 January 2022, they state that “if the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred.” For example, if a 68-year-old woman with a history of polymyalgia rheumatica presents to their primary care physician with unilateral vision changes and a unilateral headache, the doctor is likely to order, among other things, an ESR, a temporal artery biopsy, and immediately start the patient on steroids. Even if the physician didn’t document his or her rationale, an individual with appropriate medical training will know the physician is concerned about the patient suffering from temporal arteritis and the patient is at risk for permanent blindness if the situation is not dealt with in a timely fashion.


Question: With the Schizophrenia example you shared, do you feel that you are not treating that condition, but the patient having that condition, and how does it affect and determine your medication management and decisions for treatment (and possibly increase the risk for the patient in the medical decision making)?

Answer: Great question. The answer is: it will depend on the specifics of the case. For example, some medications used to treat infections, especially HIV and tuberculosis, can significantly change blood levels of antipsychotic medications. So, if a physician is treating a patient for an infection, especially HIV, and the patient is a schizophrenic who is taking certain anti-psychotic medications, the physician needs to consider the patient’s schizophrenia medications. In this case, it could increase risk of medical decision making.

Another example relates to blood pressure medications. Some ACE inhibitors, beta-blockers, and calcium channel blockers can interact with anti-psychotics. The result could be an abnormal heart rhythm or unintentional lowering of blood pressure, which could have serious effects.

This is why it is important to consider all the facts presenting in the medical record.


Question: For the 2021 guidelines you mentioned, one change was choosing those specific codes based on either MDM or Time, not both, correct?  Any recommended changes to how that statement needs to be included in patient visit documentation when billing on time?

Answer: In selecting a level for the codes discussed, the selection should be based on MDM or Time. The code does not need to meet the requirements for both, only one or the other.

There are many ways to document total time in the medical record. Some recommendations to include though include clear statements about how much time was dedicated to the individual patient and that the time excludes any time spent for any other separately reported procedures that the provider is reporting.


Question: I was wondering what your opinion is on why you think a hospital-related illness or injury was only added to the straightforward/low MDM section of Number and Complexity of Problems Addressed at the Encounter? Many conditions that require hospitalization are truly moderate or high, not straightforward/low. Seems like this was a missed opportunity to add a "hospital" related condition to other levels of MDM under Number and Complexity of Problems Addresses at the Encounter. Only one acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care was added to straightforward/low. One acute, complicated illness or injury requiring hospital inpatient or observation level of care seems like would have been reasonable to create for moderate.

Answer: This is a good question, and I don’t know for sure, but I can share a potential explanation.

I think the focus of the statement “One acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care” should be more on the word “uncomplicated” instead of the word “hospital.”

I think this is the case because the next level up for “moderate” focuses on words like “exacerbation,” “uncertain,” and “complicated.”  And for the “high” level words like “severe exacerbation” and “threat to life or bodily function” are used.  I don’t think the use of the word “hospital” is of high significance in this context because any of these levels could happen in any setting.


1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;


1 undiagnosed new problem with uncertain prognosis;


1 acute illness with systemic symptoms;


1 acute, complicated injury


1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;


1 acute or chronic illness or injury that poses a threat to life or bodily function


Question: Can you share again the links to the two source documents you referenced in the webinar?

Answer: Yes, the source documents referenced include:

  1. AMA E/M Guidelines:
  2. CMS Physician Fee Schedule Final Rule:

Question: How does the E/M selection based on using time spent with the patient justify the level of service? In some cases, the provider only counsels and answers basic questions? For 99215 that is not a high-risk visit?

Answer: Selection of the E/M level can be performed by either MDM or Time, both are not needed. If Time is selected, then none of the MDM requirements need to be met. When time is chosen as the method for selection, the documentation needs to meet the requirements for choosing the code based on time.

However, if the level is chosen based on time, the visit still needs to be medically necessary. That does not mean the MDM criteria are used, it means the time spent needs to be medically necessary. So, for example, if the provider is taking care of a neighbor and spent 10 minutes on medically necessary discussions and then 20 minutes talking about the upcoming neighborhood holiday party (which is presumably not medically necessary), the provider should only bill on the time spent that was medically necessary. Counseling and answering basic questions, as long as they are medically necessary, can count towards the total amount of time.


Question: If an orthopedist sees a patient and decides to do a knee steroid injection, and adds a note for decision regarding minor surgery with identified risks, and then performs the injection, and then charges for the injection, can that discussion of minor surgery risks with the patient also be used for MDM?

Answer: It really will depend on the documentation of the specific encounter. Assuming it is appropriate to report both an E/M with modifier -25 and the knee injection procedure on the same day, it seems from the scenario provided that the discussion of risks associated with the procedure are included in the procedure code for the knee injection itself.  In other words, performance of the knee injection includes describing its risks to the patient. Again, it is difficult to answer the question completely without having the medical record documentation.


Question: If the physician wants to do surgery but the patient refuses to have surgery, can you still count it? As you discussed with the patient?

Answer: Yes. The AMA CPT® guidelines state, “This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family.”


Question: Is it possible to get a list of the drugs requiring intensive monitoring for toxicity? Or suggest where I can find that list?

Answer: The only published lists I have seen are from local Medicare Administrative Contractors (MAC), which may or may not be your (MAC). For example, see this published list from Palmetto GBA:

  • Jurisdiction M Part B - Management Options: Drug Therapy Requiring Intensive Monitoring for Toxicity (

Question: What is the industry standard for who determines the codes to use?  Billing and coding staff or the providers?

Answer: This is an internal organization decision. Both methods have been successfully implemented throughout the healthcare industry. However, it is important for a clinical practice to know that the entity that receives the reimbursement for the service will ultimately be responsible for accuracy of claims submissions.


Question: What is your advice when you find your practice has made a mistake on coding. Do we make corrections and move on, or do we need to refund the payer and file corrected claims?

Answer: Overpayments should be refunded to payors. And many times, it would be appropriate to look further back at past claims if an audit or review shows overpayments have occurred. For example, CMS expects providers to undertake significant, proactive work to identify and return overpayments.  Healthicity has hosted webinars on the CMS 60-day overpayment rule. Visit the Healthicity resource web page to watch the recorded webinars.

Questions or Comments?