Coding Update & Guidance for 2023 CPT Evaluation/Management (E/M) Codes and Guideline Changes
Authors: The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Barbra Fisher, MD, PhD, FACOG; Brad Hart, MBA, MS, CPC, CPMA, COBGC; Trisha Malisch, CPC; Vanita Jain, MD, FACOG; & Steve Rad, MD, FACOG.
Current Procedural Technology (CPT) codes provide a uniform nomenclature for coding medical procedures and services. CPT codes first appeared in 1966, was revised periodically, and in 2000, the CPT code set was designated by the Department of Health and Human Services as the national coding standard for physician and other health care professional services under the Health Insurance Portability and Accountability Act (HIPAA). It is required that all financial and administrative health transactions sent electronically use the current code set. For this reason, it is imperative that clinicians be familiar with current updates.
The current CPT codes set is maintained by the CPT Editorial Panel, with an AMA CPT Advisory Committee composed of representatives from > 100 organizations (including the American College of Obstetricians and Gynecologists) informing decisions. The CPT code set is published annually.
Evaluation and Management (E/M) codes represent services provided by a physician or other qualified healthcare professionals. After more than 25 years of unchanged guidelines for coding office and outpatient services (including use of history, physical examination, and medical decision-making), changes to CPT 99202-99215 were modified and accepted for adoption by the Centers for Medicare and Medicaid Services on January 1, 2021. Modifications were designed to make E/M office visit coding and documentation simpler. While history and physical examination elements remain necessary to support the medical necessity of the visit, the quantity of history and examination documented is no longer relevant in informing the code level selected. In addition, the clinician can now select the appropriate level of service based on a more intuitive time-based rubric, without regard to the quantity of the visit that was dedicated to counseling.
The 2021 E/M changes substantially simplified outpatient code selection. When using Medical Decision Making as the defining factor, the level of service is now chosen based on Diagnoses, Data, and Risk, as opposed to history, examination, and medical decision making. Definitions of terms commonly used were published online, available in printed form in the AMA CPT 2021 Professional Edition book, and summarized in the 2021 SMFM Coding Document (WHA Document Template).
On January 1, 2023, major modifications to hospital inpatient and observation E/M guidelines were published. These modifications are comparable to the office E/M updates introduced in 2021. For selecting a hospital E/M level of service, one must still include appropriate history and physical examination elements to support medical necessity, however only Diagnoses, Data, and Risk are considered in choosing the appropriate code when selecting codes based on Medical Decision Making. In addition, minor modifications were made to the Diagnosis and Risk categories of the Medical Decision Making table (including addition of one LOW Diagnosis definition and two HIGH Risk definition) to facilitate use in facility-based settings. In the process, several codes were deleted, including hospital observation services E/M codes 99217-99220 and 99224-99226.
The SMFM Coding Committee created a grid to ease code selection. Similar to the 2021 SMFM Outpatient E&M Coding Guidelines grid that can be used in the office/outpatient setting, a facility-based (hospital) E&M Coding Guidelines tool was created. On side 1, there is a summary of codes, times assigned to each level of service when selecting codes based on time, and definitions for Diagnosis, Data, and Risk categories. On side 2 are examples, notes, and an updated definition of time. This two-sided tool is not meant to substitute for the CPT 2023 book, but is intended to summarize information and be a quick guide for MFMs to choose an appropriate code while at the bedside.
Grid- 2023 Facility-Based (Hospital) E&M Coding Guidelines
Grid- 2023 Outpatient (Office) E&M Coding Guidelines
Please submit any questions you may have to the SMFM Coding Committee Ask a Coding Question website (https://www.smfm.org/coding/questions/new). Additional information and resources are also available on our coding website. Thank you very much.
Sources:
AMA CPT 2023 Professional Edition 2023 CPT E/M descriptors and guidelines (ama-assn.org)