Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
Are you ready for the 2023 Evaluation and Management changes? I know I am! Honestly, I have been prepared for these changes since the Evaluation and Management changes that took effect on January 1, 2021. These changes were implemented to reduce the physician burden of documentation and coding, reduce audits through the expansion of definitions and guidelines, decrease unnecessary documentation in the record (note bloat) and ensure payment for E/M is resource-based, per the AMA. But did they? While conducting ongoing training for the 2021 E/M changes, I saw how confusing it was for providers seeing patients in both the outpatient and inpatient setting needing clarification about when to use the 2021 changes versus the 1995 and 1997 guidelines.
Let’s step back to January 1, 2021 (office and outpatient setting only codes set 99201-99215). The Evaluation and management changes were the most significant changes since the 1997 speciality guidelines. For over 20 years, providers have used the same method to document and reach their E/M levels. They were not saying that this was always easy. Routine audits showed providers were still struggling with 1995 and 1997 guidelines, and then came change, the change being the 2021 guidelines.
As of January 1, 202,1, providers in the outpatient setting did not have to worry about using History, Exam and MDM or time greater than 50% for counseling and coordination of care to reach the evaluation and management level. Instead, providers could now select the office and outpatient E/M level using either Medical Decision Making (MDM) or Time.
Before 2021 time was constituted as the typical face-to-face time the physician/qualified health care professional (QHP) spent on the day of the encounter. As of January 1, 2021, the definition was based on the total time (face-to-face and non-face-to-face) spent by a physician/qualified health care professional (QHP) on the day of the encounter and the 50% counseling and coordination of care would no longer be applicable (in this setting). Can you imagine how confused providers were? Some thought they no longer needed to document history or exams; others thought a few words were okay. Many were happy they did not need to go crazy with the detailed family history, age, and health status of family members. This did not mean providers did not need to write a history or exam but instead documented what was pertinent and relevant to today’s visit. If there was a family history of a disease that affected the patient, it should be documented. Providers want to ensure documentation is consistent from the chief compliant all the way to the MDM. If a patient is complaining of something, it should also be reflected in the history and exam.
What to expect in 2023
Fast forward to 2023, the new guidelines will include the following service areas;
Office or Other Outpatient Services
- Hospital Inpatient and Observation Care Services
- Consultations
- Emergency Department Services
- Nursing Facility Services
- Home or Residence Services
New and Established patients
The AMA has revised/clarified new vs established patients. To distinguish between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.
A new 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 speciality and subspecialty who belongs to the same group practice within the past three years.
An established patient has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same speciality and subspecialty who belongs to the same group practice within the past three years. See Decision Tree for New vs Established Patients.
If a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available, when advanced practice nurses and physician assistants are.
Time
The utilization of time can be used in all service areas listed above except the emergency department, which will only utilize time for critical care services; other ED services will utilize MDM. When documenting total time, providers also want to ensure that documentation supports the work done during the time, e.g. If you reviewed external records documented, counseling and coordination of care and ordered medication, it should be identified in the progress note/documentation. This would ensure that coders and auditors are aware of why 60 minutes of the total time is documented, but instead, the note needs to support the work done.
Per AMA revised guidelines, physician or other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and reviewing the separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported)
- documenting clinical information in the electronic or other health records
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)
Time does not include the following:
- the performance of other services that are reported separately
- travel
- teaching that is general and not limited to the discussion that is required for the management of a specific patient
Total time on the service date does not include any work done the day or days before the service date and cannot be counted as total time on the visit date.
Medical Decision Making
The 2023 changes include selecting E/M by selecting either one of these four elements, straightforward, low, moderate and high MDM. Per the AMA, the concept of MDM does not apply to 99211 and 99281. MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Three elements define MDM. The elements are:
- The number and complexity of the problem(s) addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed
- Test ordered and analyzed
- Combination of elements
- External records reviewed
- Discussion requiring interactive exchange
- Independent historian
- Independent Interpretation
- The risk of complications and/or morbidity or mortality of patient management
- Morbidity
- Surgery (minor or major, elective, emergency, procedure or patient risk)
- Drug therapy requiring intensive monitoring for toxicity
The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Therefore, presenting symptoms likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. In the aggregate, multiple problems of a lower severity may create higher risk due to interaction.
The 2023 AMA guidelines and CMS final rule should be reviewed in their entirety, and any grey areas should be addressed. This will allow everyone to grasp what constitutes a Minimal problem, Self-limited or minor problem, Stable, chronic illness, Acute, uncomplicated illness or injury, Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care, Stable, acute illness, Chronic illness with exacerbation, progression, or side effects of treatment, Undiagnosed new problem with an uncertain prognosis, Acute illness with systemic symptoms, Acute, complicated injury, Chronic illness with severe exacerbation, progression, or side effects of treatment, and Acute or chronic illness or injury that poses a threat to life or bodily function.
What’s Next
These changes were meant to lessen physician burden at a time when physician burnout has been at an all-time high due to the 2020 COVID-19 pandemic. Only time will tell how providers, coders, billers, auditors and educators acclimate to the new changes. Continued education and early chart reviews will need to be done to monitor how providers are doing with documenting and coding the new changes. I always advise pre and post-education training and a support line where providers can reach out for guidance and any resources, tip sheets and/or FAQs that can be given to help and reduce confusion. With change as big as this, it takes a collaborative team effort from everyone for implementation to be successful.
If you would like to schedule training for your organization or private practice providers or schedule a chart review email us today at info@kwadvancedconsulting.com, schedule a call or visit the website and fill out the “contact us” form.
Resources
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
https://edit.cms.gov/files/document/mssp-fact-sheet-cy-2023-pfs-final-rule.pdf
