E/M 2023—Starting Jan. 1, Streamlined Rules Apply Beyond the Office Setting

Note: This article is published online ahead of print. It will appear in the January issue of EyeNet Magazine.

Jan. 1, 2023, sees big changes to E/M coding. In a range of settings, use of E/M codes has become much less of a headache.

Streamlined Requirements Are No Longer Just for the Office

In 2021, it started with the office-based E/M codes. In 2021, CMS streamlined its documentation guide­lines for the office-based E/M codes (CPT codes 99202-99215). Before that year, you had to obtain and document a review of body systems plus a past medical history, family history, and social history, plus a chief complaint, plus elements of the history of the present illness. Additionally, examina­tion elements were required for specific levels of E/M codes.

Since 2021, docu­mentation of office-based E/M services has required only a medically relevant patient history and examination. This means that the chart only needs to document the information that will be medically relevant for the physician, and this will vary depending on the nature of the patient encounter.

Starting in 2023, the streamlined rules apply to more E/M services. In 2023, the 2021 changes for office-based E/M services will be applied to the following catego­ries of E/M services and their related families of codes:

• Hospital inpatient and observation care services
• Consultations
• Emergency department (ED) services
• Nursing facility services
• Home or residence services

Determine the appropriate level of E/M code. As with the office-based E/M codes, when using E/M codes in the above places of service you should perform and document a medically appropriate history and examination. The appropriate level of E/M code is determined by the following:

• The level of medical decision mak­ing (MDM) or
• The total time that the physician spends caring for the patient—includ­ing including before, during, and after the face-to-face encounter—on the date of the visit.

The ED exception. Levels of service for the ED E/M codes (CPT codes 99281-99285) cannot be determined by total physician time. This is because, according to the AMA, “emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”¹

99281—ED E/M Code Revised

Prior to 2023, CPT code 99281 Emer­gency department visit for the evalu­ation of a patient was selected when documentation supported a problem-focused history and exam and straight­forward MDM. Under the 2023 changes, these requirements are removed and the descrip­tor updated to: Emergency department visit for the evaluation of a patient that may not require the presence of a physician or other qualified health care pro­fessional .

E/M code 99281 (like its office-based equivalent, 99211) is for a service pro­vided by clinical staff under the super­vision of a physician. For both codes, the concept of MDM does not apply. In an ED, 99281 will rarely—if ever—be used for ophthalmology.

MDM Table Updated for Extra Places of Service

The overall complexity level of MDM can be straightforward or of low, moderate, or high complexity. You determine the overall level of MDM by looking at three decision-making com­ponents: 1) problems, 2) data, and 3) risk. If at least two components point to the same level of MDM, then that would be the overall level of MDM. If the three components each point to a different level, then the middle one determines the overall level of MDM.

Since 2021, when practices have cod­ed for an office-based encounter, they have used the Final Determination Ta­ble for MDM to determine which level of complexity those three components indicate. With MDM used to determine E/M level in other places of service, there is a new Final Deter­mination Table that includes examples from nonoffice settings. The Academy’s 2023 Final Determination Tables can be downloaded at aao.org/em for both office and hospital settings.

99418—New Add-On Code for Prolonged Services

Inpatient hospital care. When you are providing inpatient hospital care and using time as the factor for determining the level of E/M code, there could be scenarios that exceed the time designat­ed for the highest level of service. If this is the case, prolonged services should be reported. As of Jan. 1, 2023, you can use CPT code 99418 to report for each additional 15 minutes. This code re­placed codes 99354-99357, which were deleted on Dec. 31, 2022. It is an inpa­tient counterpart to 99417, which has been in use since 2021 for office-based E/M services.

When to use 99418. Only use this new add-on code if 1) time is the deter­mining factor and 2) the total time is at least 15 minutes greater than the time allotted for the highest level of service in that setting. For example, if you are using time to determine the level of E/M for a subsequent hospital inpatient visit, you would need a time of at least 50 minutes to bill 99233, which is the highest level of E/M for that service. If the total time was 65-79 minutes, you could bill 99233 + 99418; if 80-94 minutes, bill 99233 + 99418 × 2; and for every additional 15 minutes, you can bill an extra 99418.

Note: Prolonged services of less than 15 minutes are not reported

Office Consultations

Medicare Part B does not cover consul­tation codes. However, there are a few remaining commercial and/or Medicaid payers that do. If one of your payers does so, report CPT codes 99242-99245 for consultations performed in the office or other outpatient place of service. As of Jan. 1, 2023, this family of codes had descriptor changes and—as mentioned above—are selected based on MDM or total physician time. Furthermore, CPT code 99241 was deleted on Jan. 1. The lowest level of MDM, straightfor­ward, is designated as CPT code 99242.

Reminder—How to Code for Inpatient Consultations

Since 2010, you must report initial inpatient consultations with CPT codes 99221-99223 when submitting to Medi­care Part B. For subsequent consulta­tions, report CPT codes 99231-99233. These codes should be reported instead of CPT codes 99251-99255 for payers not recognizing consultations. As a result, multiple claims for inpatient hospital visits can occur on one date of service by different providers. To distin­guish between the principal physician of record (the admitting physician) and consultants, the former should append modifier –AI to the appropriate level of E/M. All other physicians (consultants) should submit the E/M code without modifier –AI.

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Coding Resources. For more information, visit aao.org/em. You also can order 2023 Fundamentals of Ophthalmic Coding.

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1 www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Accessed Nov. 3, 2022.

Prolonged Service Codes

This table demonstrates how the prolonged service codes 99417 and 99418 can be used in the office and inpatient settings, respectively.

2023 E/M Overview: Office Visits, Inpatient Hospital, and ED

When using time to determine level of E/M code, you must meet or exceed defined times, as shown below.