E/M Coding for 2023: What You Need to Know

The changes you mastered in 2021—the evaluation and management (E/M) documentation guidelines for office-based and other outpatient services—now affect other places of service, including hospital inpatient and consultations.

THE BOTTOM LINE 

For the following places of service, these E/M code families now require documentation of a medically appropriate history and examination, and the level of E/M code is determined by the medical decision making (MDM) or total physician time on the date of the encounter:

• Hospital inpatient and observation care services,
• Consultations,
• Emergency department services,*
• Nursing facility services, and
• Home or residence services.

For example, prior to January 1, 2023, the current procedural terminology (CPT) code 99222 required a comprehensive history and examination and moderate complexity of MDM. Now, this code is defined as the following (emphasis added):

• 99222: Initial hospital inpatient or observation care, per day for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.

*Exception: time is not a descriptive component of emergency department services; the code selection is based on MDM only.

REVISED CODE 

CPT code 99281 was revised for an emergency department visit that may not require the presence of a physician. This is comparable to CPT code 99211, level 1 established patient office visit, and it would rarely, if ever, be used in ophthalmology.

INPATIENT HOSPITAL VISITS 

The inpatient hospital codes have two categories: initial (CPT codes 99221–99223) and subsequent (CPT codes 99231–99233). Report these codes instead of inpatient consultations, CPT codes 99251–99255, for Medicare Part B patients and to payers that no longer accept consultation codes. Because multiple providers may report inpatient hospital visits on the same day, the admitting physician would append modifier -AI, principal physician of record.

OFFICE CONSULTATIONS 

Office consultations are also not covered by Medicare Part B. For the few payers that still cover these codes, note the following changes:

• CPT code 99241 was deleted on December 31, 2022, as the lowest level of MDM is represented in CPT 99242.
• CPT codes 99242–99245 are now selected based on MDM or total physician time:
  • 99242: straightforward MDM or 20 minutes must be met or exceeded
  • 99243: low MDM or 30 minutes must be met or exceeded
  • 99244: moderate MDM or 40 minutes must be met or exceeded
  • 99245: high MDM or 55 minutes must be met or exceeded

COMPONENTS OF MDM

For the MDM table, the same three components remain: the number and/or complexity of problems addressed at the encounter, 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.

To arrive at the final determination for a level of E/M service, two of the three components (problem, data, and risk) must have the same level of complexity out of the following: straightforward, low, moderate, or high.

Some definitions within these components have been expanded to accommodate services provided in the hospital setting. For example, there is a new problem definition of level 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care and a risk definition that includes a decision regarding hospitalization or escalation of hospital care. For updated tables, visit aao.org/em.

PROLONGED SERVICES 

When time is the determining factor for inpatient or observation services and exceeds the time limit by at least 15 minutes, report prolonged services, CPT code 99418. This new code, added on January 1, 2023, is billed in addition to the highest level of the E/M family of codes for hospital services. This new code replaced deleted CPT codes 99354–99357.

For Medicare Part B patients, report HCPCS code G0316 for inpatient or observation prolonged services instead of CPT code 99418.

For an extensive review of E/M documentation guidelines for all places of service, review the 2023 Fundamentals of Ophthalmic Coding, available at aao.org/store.