2023 Evaluation and Management Services Updates

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There are many additions and updates to the CPT E/M guidelines and here is a link to the 2023 CPT E/M Descriptors and Guidelines.

If you are coding and/or auditing evaluation and management services, you really should print the AMA document and keep it handy.

These critical updates/revisions are effective as of January 1, 2023. 

If you work for or contract with a computer-assisted coding or an encoder vendor, make sure they are updating and testing their systems now.

Deleted Codes:

• Observation Care Discharge Services (99217)
As of January 1, 2023, assign Hospital Discharge Services 99238 or 99239 for observation care discharge services
• Initial Observation Care (99218-99220)
As of January 1, 2023, assign Initial Hospital Care 99221-99223 for initial observation care
• Subsequent Observation Care (99224-99226)
As of January 1, 2023, assign Subsequent Hospital Care 99231-99233 for initial observation care
• Office or Other Outpatient Consultations (99241)
As of January 1, 2023, assign 99242-99245
• Inpatient or Observation Consultations (99251)
As of January 1, 2023, assign 99252-99255
• Other Nursing Facility Services (99318)
As of January 1, 2023, assign 99307-99310
• Domiciliary, Rest Home, or Custodial Care Services – New Patient (99324-99328)
• Domiciliary, Rest Home, or Custodial Care Services – Established Patient (99334-99337)
As of January 1, 2023, assign 99341, 99342, 99344, or 99345 (new patient)
As of January 1, 2023, assign 99347-99350 (established patient)
• Domiciliary, Rest Home, or Home Care Plan Oversight Services (99339, 99340)
As of January 1, 2023, assign 99347, 99491 or 99424, 99425
• Prolonged Services – Outpatient (99354, 99355)
As of January 1, 2023, assign 99417
• Prolonged Services – Inpatient, Observation, or Nursing Facility (99356, 99357)
As of January 1, 2023, assign 993X0

New Code:
• 993X0
This is a new add-on code for 2023 to report prolonged service time for inpatient or observation with or without direct patient contact. This code is to be reported in addition to 99223, 99233, 99236, 99255, 99306, and 99310.

Revised Codes Descriptions:

The following categories are revised to align with the 2021 code structure for office visits.

Effective as of January 1, 2023, these categories will only require a medically appropriate history and/or examination. The E/M level will be assigned based upon the level of Medical Decision Making or Time except for Emergency Department Services where time is not a factor.

Note the 2023 changes in Time for each E/M level!

• Initial Hospital Inpatient or Observation Care (99221-99223)
99221 – 40 minutes
99222 – 55 minutes
99223 – 75 minutes
Services 90 minutes or longer, use prolonged services codes

• Subsequent Hospital Inpatient or Observation Care (99231-99233)
99231 – 25 minutes
99232 – 35 minutes
99233 – 50 minutes
Services 65 minutes or longer, use prolonged services codes

• Hospital Inpatient or Observation Care Services – Including Admission and Discharge Services (99234-99236)
99234 – 45 minutes
99235 – 75 minutes
99236 – 85 minutes
Services 100 minutes or longer, use prolonged services codes

• Office or Other Outpatient Consultations
99242 – 20 minutes
99243 – 30 minutes
99244 – 40 minutes
99245 – 55 minutes
Services 70 minutes or longer, use prolonged services code 99417

• Inpatient or Observation Consultations
99252 – 35 minutes
99253 – 45 minutes
99254 – 60 minutes
99255 – 80 minutes
Services 95 minutes or longer, use prolonged services codes

• Initial Nursing Facility Care
99304 – 25 minutes
99305 – 35 minutes
99306 – 45 minutes
Services 60 minutes or longer, use prolonged services codes

• Subsequent Nursing Facility Care
99307 – 10 minutes
99308 – 15 minutes
99309 – 30 minutes
99310 – 45 minutes
Services 60 minutes or longer, use prolonged services codes

• Home or Residence Services – New Patient
99341 – 15 minutes
99342 – 30 minutes
99343 – This code is not listed in the updates as deleted or revised. Stay tuned for the Addendum
99344 – 60 minutes
99345 – 75 minutes
Services 90 minutes or longer, use prolonged services code 99417

• Home or Residence Services – Established Patient
99347 – 20 minutes
99348 – 30 minutes
99349 – 40 minutes
99350 – 60 minutes
Services 75 minutes or longer, use prolonged services code 99417

• Emergency Department Services (99281-99285)
Time is NOT a descriptive component for services in the Emergency Department. The overall level of E/M services will be based upon the level of Medical Decision Making.

Effective January 1, 2023, some of the descriptors for the levels of Medical Decision Making will be revised:
99281 – was Straightforward MDM. For 2023, the descriptor is “may not require the presence of a physician or other qualified health care professional”
99282 – was Low complexity MDM. For 2023, the descriptor is Straightforward MDM
99283 – was Moderate MDM. For 2023, the descriptor is Low MDM
99284 – was and will remain Moderate MDM for 2023
99285 – was and will remain High MDM for 2023

2023 ICD-10-CM Updates – Chapter-Specific Guidelines

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I know it’s the same coffee as last week, but it has become my new obsession for the Summer.

Let’s jump right into the changes/updates to the 2023 chapter-specific guidelines.

C. Chapter-Specific Coding Guidelines

 Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

a. Human Immunodeficiency Virus (HIV) Infections

                        2) Selection and sequencing of HIV codes

                                (a) Patient admitted for HIV-related condition

 The chapter-specific rule is to assign principal (primary) diagnosis B20 when patients are admitted for an HIV-related condition and additional diagnosis code(s) for all documented HIV-related condition(s). 

2023 has an exception: 

If the admission is hemolytic-uremic syndrome and it is documented as associated with HIV disease, assign principal (primary) diagnosis D59.31 and secondary diagnosis B20.

D59.31 is a new ICD-10-CM code for 2023.  We will review the new, deleted, and revised codes next week.

• HIV managed by antiretroviral medication

2023 guideline specifies “antiretroviral” medication and includes HIV-related illness or AIDS.

                        3) Sequencing of severe sepsis

                                For infection-associated hemolytic-uremic syndrome with severe sepsis, see guideline I.C.1.d.9.

                       4) Sepsis or severe sepsis with a localized infection

                                For infection-associated hemolytic-uremic syndrome with severe sepsis, see guideline I.C.1.d.9.

 This is I.C.1.d.9:  (New guideline)

                        9) Hemolytic-uremic syndrome associated with sepsis

If hemolytic-uremic syndrome is documented as associated with sepsis, assign D59.31 (new code for 2023) as the principal (primary) diagnosis.  The underlying systemic infection and other conditions should be coded as additional diagnoses.

            g. Coronavirus infections

1) COVID-19 infection (infection due to SARS-CoV-2)

                                    (n) Underimmunization for COVID-19 Status (new guideline published for 2023), but the codes have been available for reporting since April 1, 2022

 Chapter 2: Neoplasms (C00-D49)

General Guidelines

1. Admission/Encounter for treatment of primary site

I had to read this one a few times to understand the change.

Before 2023, the guideline focused on the treatment directed at the malignancy.  For 2023, if the malignancy is the reason for the admission/encounter and treatment is directed at the primary site, the primary malignancy will be reported as the principal/primary diagnosis.  The exception remains the same.  If chemotherapy, immunotherapy, or external beam radiation therapy is the reason for the admission/encounter, report the Z-code as primary.

t. Secondary malignant neoplasm of lymphoid tissue

This guideline is new for 2023 and addresses malignant neoplasm of lymphoid tissue that metastasizes beyond the lymph nodes.  For 2023, do not assign a code for the secondary neoplasm of the affected solid organ.  Instead, coders should assign a code from category C81 through C85 with a final character “9.4.

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

1. Diabetes mellitus

3)Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs

For 2023, instead of “oral medications and insulin,” the guideline specifies oral hypoglycemic drugs and insulin. In addition, it directs us to another new code for 2023, Z79.85, for Long-term (current) use of injectable non-insulin antidiabetic drugs.

Chapter 5: Mental, Behavioral, and Neurodevelopmental disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

1) In Remission

For 2023, this section now includes the addition of new codes that are assigned “.91” to describe “in remission”.  I’ll provide more detail of these new codes next week.

d. Dementia (new guideline for 2023)

There are many new codes for this category in 2023. 

If providers do not document the severity of Dementia (and coders cannot query the providers), coders are directed to assign the appropriate code for unspecified severity.

For inpatient stays, when patients are admitted with a specific level of severity, and it progresses to a higher level, coders should assign the code for the highest severity level reported during the stay.

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

1. General Rules for Obstetric Cases

7) Completed weeks of gestation

This guideline clarifies how to assign code for “completed” weeks of gestation with an example.  We are instructed to code only the whole weeks, not the “days” (24 weeks, 4 days).

• Termination of Pregnancy and Spontaneous abortions (new guideline for 2023)
• Hemorrhage following elective abortion

Do not assign code O72.1 – this code is reported for postpartum hemorrhage. Likewise, do not assign code Z33.2 when the patient experiences a complication (post-elective abortion hemorrhage).  The correct code is O04.6.

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

e. Adverse Effects, Poisoning, Underdosing, and Toxic Effects

5) The occurrence of drug toxicity is classified in ICD-10-CM as follows:

                        (c) Underdosing

I’m just going to provide the quote, “Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.”

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

            10) Counseling

“Code Z71.87, Encounter for pediatric-to-adult transition counseling, should be assigned when pediatric-to-adult transition counseling is the sole reason for the encounter or when this counseling is provided in addition to other services, such as treatment of a chronic condition. If both transition counseling and treatment of a medical condition are provided during the same encounter, the code(s) for the medical condition(s) treated and code Z71.87 should be assigned, with sequencing depending on the circumstances of the encounter.”

            17) Social Determinants of Health

This guideline has been updated for 2023 to include the language, problems or risk factors related to social determinants of health. 

Coders should assign all SDOH codes to describe the problems or risk factors only when the providers document that the patient has an associated problem or risk factor.

Next week, we will review the 2023 ICD-10-CM code additions, deletions, and revisions.

Yes, I’ll be sipping more Starbucks® Bottled Caramel Frappuccino® Coffee Drink.

Forget What You Thought You Knew – Evaluation & Management MDM

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Auditing and educating never ends.

After completing focused audits on the 2021 Evaluation and Management MDM changes, I met with a group of coders.

The audit results and the feedback from the coders were concerning.

Are you sure you’re staying up to date on the changes in MDM?

Only 40% of the coders scored over 90% in the audits. 

The failures were due to the coders not correctly translating MDM according to AMA’s revisions.

Some were not aware of AMA’s FAQ page.  This is a valuable source for clarification.  Are you correctly translating MDM?

According to AMA:

•  Coders “should not determine whether a patient’s medical problem or  illness is stable or worsening.”

Providers are responsible for clearly documenting the status of the condition. 

• The distinction between minor surgery and major surgery is not based on the global period assigned to the surgical procedure code.

“The physician or QHP who evaluates the patient is the best judge of the specific patient factors that make a procedure “high risk” for a patient. Every surgical procedure carries some element of risk; however, a relatively simple procedure for an otherwise healthy adult carries a different level of risk than the level of risk for an older patient with multiple comorbidities.”

The provider must document whether the procedure is major or minor.

So, whether or not there’s a webinar that offers CEU’s, coders are responsible for staying up to date on coding and industry changes. 

We’re responsible for our coding accuracy and providing accurate feedback to our physicians.