Ready to learn about the 2023 CPT® E/M changes? There is a significant update to the Evaluation and Management (E/M) section of the CPT® book. There are 25 codes that are going away. There are revisions to the introductory guidelines related to five different categories of codes. Prolonged services are getting yet another overhaul. This article discusses the American Medical Association’s E/M changes, but does not include how Medicare is proposing to accept–or not–these codes and policies. That will be addressed in a later article.
Here are the codes that are being deleted.
- Hospital observation services codes 99217—99220, 99224–99226
- Consultation codes 99241, 99251
- Nursing facility service 99318
- Domiciliary, rest home (eg, boarding home), or custodial care services, 99324—99328, 99334-99337, 99339, 99340
- Home or resident services code 99343
- Prolonged services codes 99354—99357
Initial and subsequent services
There is a new section titled initial and subsequent services which applies to hospital inpatient, observation care and nursing facility codes. It applies to both new and established patient visits. The AMA says,
“For the purpose of distinguishing between initial or subsequent visits, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management 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.”[1]
- These codes are used by physicians and other qualified health care professionals who have E/M services in their scope of practice
- It explains the rules for physicians and other qualified health care professionals who are working in the same specialty and subspecialty in the same group practice. During an inpatient, observation, or nursing facility stay, the group may bill only one initial service, and follow up services are billed with subsequent visits. This is not a change in how groups are reporting inpatient or observation services. When partners are covering for one another, the practitioner who does the initial service bills for the initial service and on subsequent days covering physicians report a subsequent visit. It is aligned with the Medicare rule that physicians in the same group of the same specialty should bill and be paid as if they were one physician.
Selecting a level of service using 2023 CPT® E/M changes
As expected, the AMA has extended the framework for code selection for office and outpatient visits that was implemented in 2021 to the remainder of E/M services that were selected based on history, exam, medical decision making or time.
The change affects these services:
- Hospital inpatient and observation care services (one set of codes will be used for both inpatient and observation)
- Consultation services
- Emergency department services (time may not be used as a factor when selecting an ED visit)
- Nursing facility services
- Home or residence services
For the categories of codes listed above, the level of E/M service may be selected by the medical decision-making or time. (Time is not a factor in selecting ED visits.) Code selection will be based on the three elements of medical decision making which are: the number and complexity of problems that are addressed during the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications or morbidity or mortality of patient management. This article provides an overview of the 2023 CPT® E/M Changes. There are additional resources on CodingIntel that describe selecting the level of service. Those resources will be updated to reflect the changes that the AMA made in their discussion of medical decision-making.
Hospital inpatient and observation care services
With the deletion of observation codes 99217—99220, and 99224—99226, the same codes will be used to report services for patients who are in observation or are inpatients. There are two sets of codes. One set is for use when the patient is admitted and discharged on the same calendar day, 99234–99236. And the other set is for patients whose stay is longer than a single calendar day. These are 99221–99223 for the initial service, 99231—99233 for subsequent visits and 99238 and 99239 for discharge services.
CPT® says that when the conditions for a consultation are met, codes 99252-99255 may be reported by a consulting physician in the inpatient setting. Medicare, of course, does not recognize these codes and many private insurances also stopped recognizing these codes.
In the guidelines for this section, CPT® repeats that when advanced practice nurses and physician assistance are working with physicians, they are considered to be working in the exact same specialty and subspecialty. The AMA also has changed its guidance on admitting a patient from another site of service. It is unlikely that Medicare or other players will follow this guidance but this is what the AMA says.
“When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.”[2]
The AMA also notes that if a patient transitions from inpatient or observation or from observation to inpatient, it does not constitute a new stay. That is, don’t bill an additional initial service if the patient’s status changes.
Admission and discharge on the same calendar date
Codes 99234—99236 are used for hospital inpatient or observation care and include the admission and discharge on the same date, whether the patient is an inpatient or in observation level care. CPT states that in order to report these services, there must be two encounters, the admission and discharge. The documentation should reflect that the patient was seen twice. While CMS is recognizing and paying for these services, in order to report them the patient must be in the facility for >8 hours. This is unchanged CMS policy, but is not a CPT rule.
The Physician Final Rule had a table indicating what codes to bill when the patient was and wasn’t in the facility for 8 hours or more. Below, is the table reproduced with an additional column for CPT rules and codes added to the descriptions in the CMS rule.
| CMS and CPT rules for admission and discharge, same calendar date with application of CMS 8 hour rule | |||
| Hospital Length of Stay | Discharged On | Code(s) to Bill CMS | Code(s) to Bill CPT |
| < 8 hours | Same calendar date as admission or start of observation | Initial hospital services only 99221–99223 | Adm/Discharge 99234–99236 |
| 8 or more hours | Same calendar date as admission or start of observation | Adm/Discharge 99234–99236 | Adm/Discharge 99234–99236 |
| < 8 hours | Different calendar date than admission or start of observation | Initial hospital services only 99221–99223 | Initial and discharge, 99221–99223 on adm. 99238-99239 on d/c |
| 8 or more hours | Different calendar date than admission or start of observation | Initial and discharge, 99221–99223 on adm. 99238-99239 on d/c | Initial and discharge, 99221–99223 on adm. 99238-99239 on d/c |
How do the 2023 CPT® E/M changes affect reporting consultation codes?
The two low level consult codes 99241 and 99251 are deleted. The comments in this section are considerably reduced from the 2022 book. CPT® clarifies two things that won’t come as a surprise for most people. Consultations must be requested by another health care professional, not the patient’s family or lawyer or a non-clinical social worker. And the consultant’s opinion and any services that were ordered or performed must be communicated by written report to the requesting physician or other qualified healthcare professional. CPT® says to use codes 99242-99245 for service in the office or other outpatient setting including home and the emergency department. Codes 99252-99255 are used in hospital inpatients, for observation level patients, for residents in a nursing facility and for patients in a partial hospital setting. A consult is only used once per stay per specialty and group.
Consults require a request from another health care professional or appropriate source and a written report. Document both of these in the consult note. The concept of transfer of care is removed from the 2023 CPT book and no longer is a lens with which to evaluate consults.
Medicare does not intend to change its policies and does not recognize these codes.
Emergency department services
ED visits are not defined as new or established patients. When selecting a level of service in 2023, use medical decision-making. Time is not a factor in ED visits. Code 99281 has a descriptor change. It is now defined as “Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.” This makes it like code 99211, that does not require the presence of a physician or other qualified health care professional. However, a medical practice may not bill 99281 for services performed by a hospital employed nurse, and Medicare does not allow incident to services in a facility. It is difficult to see when a medical group would report 99281.
Nursing facility services
The codes in this section are used for patients in nursing facilities, skilled nursing facilities, psychiatric residential treatment centers, and immediate care facilities for individuals with intellectual disabilities. The editorial comments are significantly revised from the 2022 book. The AMA describes the principal physician as the admitting physician and is the clinician who oversees the patient’s care. Other physicians and qualified health care professionals may also see the patient.
“Modifiers may be required to identify the role of the individual performing the service.”[3]
Although that CPT® book doesn’t say this, I assume the modifiers in question would be HCPCS modifiers that identify the principal physician, AI, or a nurse practitioner or physician assistant as performing the service.
The AMA notes that there is a high-level medical decision-making specific to initial nursing facility cares by the principal physician or other qualified health care professional. This is in the element related to the number and complexity of problems addressed at the encounter. It is:
“Multiple morbidities requiring intensive management: A set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations. The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital.
The definitions and requirements related to the amount and/or complexity of data to be reviewed and analyzed and the risk of complications and/or morbidity or mortality of patient management are unchanged.◄”[4]
That is, the AMA is adopting a unique definition in the number and complexity of problems addressed for initial nursing facility services. Note that the other two elements are unchanged for initial nursing facility services.
The AMA says that the initial nursing facility services may be used once per admission per physician or other qualified health care professional, regardless of the length of stay. The AMA aligns itself with Medicare rules in saying that the initial comprehensive visit in a skilled nursing facility must be done by a physician. In a nursing facility (the distinction is not in a skilled nursing facility) the AMA says qualified health care professionals may report the initial comprehensive nursing facility visit if allowed by state law or regulation.
Initial services by physicians and other qualified healthcare professionals who are not the admitting or principal physician for the patient in the nursing home may be reported with initial nursing facility or consultation codes according to the CPT® book.
The two nursing facility discharge services, 99315 and 99316 are time-based codes. They include all of the time spent on the day that the physician or other qualified health care professional has a face-to-face visit with a patient. Report the service on the day that the practitioner sees the patient, even if it is not the day that the patient is discharged from the facility.
Home or residence services
Domiciliary, rest home or custodial care services codes are now deleted. To report services to patients in those facilities, use the home or residence services codes. For new patients, these are codes 99341, 99342, 99344, 99345. Code 99343 is deleted. There are four levels of new patient home or resident services. There are also four levels of established patient home or residence services, using codes 99347—99350. The AMA states that if selecting a code based on time, you may not include travel time.
Prolonged care codes receive a lot of attention in the 2023 CPT® E/M changes
CPT® is deleting prolonged codes 99354, 99355, 99356, and 99357. These were face-to-face prolonged care codes that could be used with office/outpatient codes or inpatient, observation or nursing facility. CPT® is keeping non-face-to-face prolonged care codes 99358 and 99359 for when the services are performed on a date other than a face-to-face visit. There is a long list of services which may not be reported on the same date, and you may never double count time spent, so there a long list of services for which CPT® says don’t include the time of non face-to-face prolonged care when you’re reporting these other care management services. As a sidenote, CMS is proposing to give codes 99358 and 99359 a status indicator of invalid, which would make them non-payable for Medicare patients.
CPT® is revising the editorial comments for prolonged clinical staff codes 99415 and 99416. These codes are also not payable by Medicare.
Existing prolonged care code 99417 which currently may be used only with 99205 and 99215 will be reported with outpatient consult code 99245, home visit codes 99345 and 99350, and cognitive assessment code 99483 in 2023.
The AMA is developing a new prolonged care code, which is not released in its July guideline. The placeholder code that the AMA is using is 993X0 for additional 15-minute increments of time with or without patient contact to be used with hospital codes 99223, 99233, and 99236, and consult code 99255, and nursing facility codes 99306 and 99310. The prolonged services codes may now only be used with the highest level code in the category or subcategory. It won’t surprise you to learn that in the Medicare proposed rule, they are developing additional HCPCS codes for prolonged care, and will not recognize the CPT® codes.
The 2023 CMS Proposed Physician Rule Webinar will describe the policy proposals in the 2023 Proposed Physician Rule. At the end of the session, participants will be able to:
- Describe the timeline for comments and the final rule
- List policy changes that will affect their practices in the next year
Article References:
[1] https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf p. 4, Accessed July 5, 2022
[2] Ibid p. 23
[3] Ibid p. 31
[4] Ibid p. 31
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