Evaluation of New Codes and Guidelines
New guidelines and code descriptions were issued by the American Medical Association in 2021 for the offices and outpatient E/M codes. Though, the one notable change is the removal of the History and Examination sections from the process of scoring used to determine the E/M level of service. Starting from January 1, 2023, E/M services performed in outpatient settings will be carried over across all healthcare settings, including hospitals, emergency departments, nursing facilities, and patients’ homes.
2023 CPT Documentation Guidelines for Evaluation and Management (E/S) service recreate the guidelines for the following E/M categories:
- Emergency Department Services (ED)
- Home Residence Services
- Nursing Residence Services
- Hospital inpatient and observation care services
- Prolonged Service with or without Direct Patient Contact on the Date of an E/M Service
E/M Changes for ED Services
Here are a few key changes:
- 2023 ED E/M reporting guidelines and definitions for codes 99281–99285:The meanings of ED E/M codes 99281–99285 for 2023 are as follows:
- 99281: Visit the emergency department for the examination and management of a patient who might not need to see a doctor or other certified health care provider in person.
- 99282:A visit to the emergency department (ED) for the evaluation and management of a patient that necessitates a straightforward medical assessment, a medically appropriate history, and/or an examination.
- 99283:An emergency department visit for the evaluation and management of a patient that necessitates a low-level medical decision-making history and/or examination.
- 99284: ED visit for the evaluation and care of a patient requiring a considerable amount of medical judgment in the form of history taking and/or physical examination.
- 99285:A visit to the emergency department (ED) for the evaluation and management of a patient that necessitates a medically necessary history, examination, and/or high-level medical decision-making.
The 2023 changes to the documentation guidelines do not affect the critical care codes (99291 and 99292)
For evaluating ED E/M service level, there are new regulations:
- The amount of ED E/M service will be determined by Medical Decision-Making (MDM). Just as medically necessary, a history and examination are required. The previous criteria to record E/M services in the ED based on a thorough medical history, physical exam, and MDM have been eliminated as of 2023. The sole criterion for code selection in 2023 will be MDM as per the revised standards, which merely call for a medically adequate history and physical examination
- The transformed historical three MDM components will continue to form the foundation of MDM:
1: The quantity and complexity of problems addressed
2: The quantity and/or complexity of the data that must be examined and processed.
3: The potential for complications, morbidity, or mortality associated with patient management. In 2023, the level of an ED E/M code will be determined by the highest two of the three MDM components
- Since code 99281 will not necessitate the presence of a doctor or other competent health care professional, the level of MDM concept will not apply to this level of service (QHP).
- Critical Care services and ED E/M services may be reported jointly.
- Nurse staff may submit a 99281: Nursing personnel must make sure that the services provided are documented and make it clear that the work they did is not a component of another independently reportable service to submit service report number 99281. If the provider is not reporting an E/M service during the same contact, code 99281 could be recorded for the removal of suture materials, a dressing change, or any other separately reportable service.
- Time is NOT a factor when choosing ED levels of service because ED services are frequently delivered at various intensities, frequently involving multiple encounters with numerous patients over a lengthy time, and tracking precise times spent on each patient during concurrent active management would be next to impossible
- Medical Necessity: The doctor or QHP must decide if the type of problem that is being presented supports the need for the services being provided. The main factor in determining the amount of ED E/M care will be medical needs.
The 2023 E/M modifications are intended to minimize the administrative load on healthcare providers, streamline coding and documentation requirements, and improve patient health. A realistic choice for providers to ensure correct reporting of services to prevent audits and assure proper reimbursement is to partner with an experienced provider of emergency room billing services.