Understanding the Evaluation and Management (E/M) Level Coding Changes for 2023

In 2021, significant coding changes were made to the Current Procedural Terminology (CPT) codes for outpatient evaluation and management, effective January 1, 2022. These changes were enacted to reduce the administrative burden on clinicians. With those changes, Evaluation and Management (E/M) levels are currently determined by total time or medical decision making (MDM). New patient E/M codes (99202-99205) and established patient E/M codes (99212-99215) no longer require the three components or time for counseling and coordination of care. Instead, a medically appropriate history and examination are required, but the code selection is determined by the level of the medical decision-making or total time spent on the day of the encounter date. The number of minutes required for each code has increased as well.

In 2022, we are now preparing for additional coding changes scheduled to be implemented January 1, 2023. Significant E/M code changes for the following service types include Inpatient/Observation – Deletion of observation codes 99217-99226 with added language to the initial and subsequent inpatient codes 99221-99223 and 99231-99233.

The information discussed within this article is a reflection from the discussion of the most recent Panel meeting as of February 2021 by the American Medical Association (AMA). Release of more specific code set information will be timed with the release of the complete set of coding changes in the CPT publication. [1]

Per the panel action there are approximately 37 distinct code names that have been accepted for changes including revisions, deletions, or additions.

The E/M revisions are intended for face-to-face interaction with the patient and to simplify coding and documentation requirements for health care providers and improve patient health under the following principles:

• To decrease administrative burden of documentation and coding and align CPT and Centers for Medicare & Medicaid Services (CMS) guidelines whenever possible;
• To decrease the need for audits;
• To decrease documentation in the medical record that is not needed for patient care; and
• To ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties. [2]

Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital inpatient and observation care visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes.

The following service types will include significant changes:

• Inpatient and Observation Care Services – Deletion of observation codes 99217-99226 with revisions and added language to the initial and subsequent inpatient codes 99221- Revisions of codes 99221-99223, 99231-99236, 99238, 99239 to include observation care services; and revisions of the Hospital Inpatient Services subsection including heading and guidelines.
• Consultations – Deletion of 99241 and 99251 which similarly reflect the deletion of level one services that went into effect this year for 99201. Revisions of codes 99242-99245, 99252-99255 and revision of the Consultations section include heading and guidelines.
• Emergency Department Services – Revision of codes 99281-99285 and revision of the Emergency Department subsection guidelines.

Following are the key revisions to the ED E/M codes that will become effective with the CPT 2023 code set:

• E/M services in the ED that were selected based on key components (history, examination and medical-decision-making [MDM]) will be selected based on MDM alone for services provided in 2023.
• No distinction will be made between new and established patients in the ED; E/M services in the ED category may be reported for any new or established patient who presents for treatment in the ED.
• Time will not be a descriptive component for the ED levels of E/M services because ED services typically are provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
• The highest two of three elements of MDM will be used to select the level of an ED E/M code:
  1. Problem(s): the number and complexity of presenting problems;
  2. Data: the amount and/or complexity of data to be reviewed and analyzed; and
  3. Risk: The risk of complications and/or morbidity or mortality of patient management.
• The concept of the level of MDM will not apply to code 99281 because this level of service will not require the presence of a physician/other qualified health care professional (QHP).
• All levels of ED service will include a medically appropriate history and examination as determined by the treating physician/QHP.
• As medical necessity will be an overarching criterion for selecting the level of ED E/M service, the physician/QHP will have to consider whether the nature of the presenting problem supports the medical necessity of services rendered.
• Prolonged Services – Addition of 2 new codes 908X0 and 903X0, deletion of 99345 -99357 and revision of codes 99417 and 99483. As of 2021, codes 99345-99357 cannot be used with office visits
• Home and Residence Services- Deletion of 12 E/M codes and revision of 8 E/M codes with guideline revisions in both areas. Appears to consolidate these services as many are repetitive. Deletion of the Domiciliary, Rest Home (e.g., Boarding Home) or Custodial Care Services subsection including guidelines. Revision of the Domiciliary, Rest Home (e.g., Assisted Living Facility) or Home Care Plan Oversight Services section including guidelines

While this summarizes the proposed EM coding changes, there may be other notable code changes. The AMA summary is located here.

[1] CPTu00ae Editorial Summary of Panel Actions February 2021

[2] Emergency Department E/M Codes Revised for 2023