Aalc Enm Update 2023

2023 Evaluation &
Management Updates (AMA

Updates)
Padmaja Chilaka CPC,CPMA
2023 E/M
Guidelines
Disclaimer
This presentation is designed to offer basic information for coding
and billing. The information presented here is based on the
experience, training and interpretation of the author. Although
the information has been carefully researched and checked for
accuracy and completeness, the instructor does not accept any
responsibility or liability with regard to errors, omissions, misuse
or misinterpretation. This material is intended as an Educational
guide and should not be considered a legal/consulting opinion.
Evaluation and Management
E VA L U AT I O N A N D M A N A G E M E N T C O D I N G , T O D AY A N D T O M O R R O W
1997-2010
1992 1995 July 1, 2022
Refining of
AMA created CMS Published Guidelines (2000 AMA finalized 2023
E/M codes Calculations proposal rejected) E/M revisions
Nov. 1, 2019
1994 1997
CMS finalized 2021 office
CMS Revision of and other outpatient E/M
Marshfield Calculations
Clinic Beta revisions (implementation
Tool 1/1/2021)
Deleted & Revision Codes
Evaluation and Management Categories for face-to-face encounter with the patient and/or
family:
• Office or Other Outpatient Services
• For 99211, the face-to-face services may be performed by clinical staff
• Hospital Inpatient and Observation Care Services
• Consultations
• Emergency Department Services
• For 99281, the face-to-face services may be performed by clinical staff
• Nursing Facility Services
• Home or Residence Services
• Prolonged Service With or Without Direct Patient Contact on the Date of an Evaluation
and Management Service
Deleted & Revision Codes
Deleted Additions/Revisions
99217 - OBS Discharge 99238, 99239
99218 - 99220 - Initial OBS 99221 - 99223
99224 - 99226: Subsequent OBS 99231 - 99233
99241 & 99251: Outpatient & Inpat Consultations 99242
99318: Nursing Facility Service 99307 - 99310
99324 - 99328: Domiciliary, rest Home, Custodial New Patient 99341, 99342, 99334 , 99345
99334 - 99337: Domiciliary, rest Home, Custodial Est Patient 99347 - 99350
99339 - 99340: Domicilliary, rest Home, Home Care CPO 99437, 99491, 99424, 99425
99343: Home or Residence Services 99341 - 99345
99356 - 99357: Prolonged Service Inpatient pr OBS 993X0
New & Established Patient
New Vs Established
Nurse Practitioners and

Physician Assistants
working with physicians,
they are considered as
working in the exact same
specialty and subspecialty
as the physician.
Covering or “on-
call” providers
should select the
relationship code
the unavailable
provider would
have used.
Initial vs Subsequent
MDM & Time
Coders and providers are required to choose E/M visit levels based on either:
 Medical Decision Making (using the new office/OP revisions MDM table) or
 Total time spent on the day of the visit (using the new time ranges)
Use whichever method allows the highest appropriate reimbursement, however,
 Certain categories may only have time as a reporting component (e.g., critical care).
 Other may not have time as a component(e.g., emergency department) and are solely based
on MDM.
Problem
Prob lem
MDM
Risk Data
MDM
Medically Medically
Appropriate Appropriate
History Exam
Medical Decision Making
Chief Complaint – Reason for the visit
Brief
statement,
usually in the
patients own the
words, that Concise reason(s)
describes the statement
describing for the
reason the encounter.
patient is seeing
the physician.
Number/Complexity of Problems Addressed – Problem Minimal
Minimal
•A problem that may not require the presence of a provider, but the service is provided
under the provider’s supervision
Self-limiting or Minor Problem
•A problem that is temporary and runs a definite prescribed course, is temporary in nature,
and is not likely to permanently affect the patient’s health status
Number/Complexity of Problems Addressed – Problem Low
Stable, Chronic Illness
Acute, Uncomplicated Illness or Injury
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care:
Stable, acute illness

Number/Complexity of Problems Addressed – Problem Low
Elements of Medical Decision Making

Number and Complexity of Problems Addressed
at the Encounter
Low
❑2 or more self-limited or minor problems;
Or
❑1 stable, chronic illness Or
❑1 acute, uncomplicated illness or injury
Or
❑1 stable acute illness Or
❑1 acute, uncomplicated illness or injury requiring hospital inpatient
or observation level of care.
Number/Complexity of Problems Addressed – Problem Moderate
Chronic Illness with Exacerbation, Progression, or Side Effects of Treatment
Number/Complexity of Problems Addressed – Problem Moderate
Number and Complexity of Problems Addressed
at the Encounter
Moderate
❑1 or more chronic illnesses with exacerbation, progression, or side effects of

treatment;
Or
❑2 or more stable chronic illnesses;
Or
❑1 undiagnosed new problem with
uncertain prognosis;
Or
❑1 acute illness with systemic symptoms;
Or
❑1 acute complicated injury
Number/Complexity of Problems Addressed – Problem High
Chronic Illness with Severe Exacerbation, Progression, or Side Effects of Treatment
•The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk
of morbidity and may require escalation in level of care.
Acute or Chronic Illness or Injury that Poses a Threat to Life or Bodily Function
Acute
•An acute or Chronic
illness Illness
with systemic or Injury
symptoms, that complicated
an acute Poses a Threat
injury, to
or Life or Bodily
a chronic Function
illness or injury with exacerbation
and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without
treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life
or bodily function. These may be included in this category when the evaluation and treatment are consistent with this
degree of potential severity

Number and Complexity of Problems Addressed at the Encounter
High
❑1 or more chronic illnesses with severe
exacerbation, progression, or side
effects of treatment;
Or
❑1 acute or chronic illness or injury that
poses a threat to life or bodily function
Number/Complexity of Problems Addressed
• The complexity of the presenting problem, TODAY. For example,

Hypertension (HTN) (I10)
Number/Complexity of Problems Addressed – Problem High
• Nature of the condition.

• Self-limiting or minor patients
whose recovery may not require
treatment or medication
intervention.
• Patients where the natural course of
a condition may be considered self-
limiting, minor or acute, but for a
specific patient where the condition
warrants chronic treatment to
improve and become stable,
document the treatment goal and
the supporting exceptions for the
problem complexity.
Number/Complexity of Problems Addressed
• Symptoms that may cluster around a

specific diagnosis are not necessarily a
unique condition, such as fever as the
result of flu.
• If symptoms are all expected to be related
to one problem (even if there is not yet an
established diagnosis) the symptoms should
not be counted separately, unless provider
states they are not likely to be from the
same source.
Services Reported Separately
• The ordering and actual performance and/or interpretation of diagnostic test/

studies during a patient encounter are NOT included in determining the levels of
E/M services when the professional interpretation of those test/studies is reported
separately by the physician or other QHP reporting the E/M service.
Reporting of tests – Independent interpretation & ordered/reviewed
Question Answer
Can point of care tests that are results Yes, these simple tests that do not
only—such as dipstick UA, quick strep require separate interpretation can now
and CBC—be counted as ordered or be counted as order/review as part of
reviewed for selecting an MDM level even Data in MDM, even if the test was
if the CPT code is billed for those tests? reported by the physician/QHP
performing the office E/M
If a test does not require separate interpretation (e.g., results only tests) AND
• Is analyzed as part of the MDM
• Counts as 1 item towards ordered/reviewed in Data
Amount/Complexity of Data Reviewed & Analyzed
Data Complexity
Category 1: Tests and documents

•
Any combination of from the following:

Review of prior external note(s) from each unique source*;
An external physician o r other QHP

who is not in the same gro up
A unique so urce is defined as: practice o r is of a d ifferent
External reco rds, co mmunicatio ns a physician o r qualified heath care specialty o r subspecialty.
and/o r test results are fro m: professio nal in a d istinct gro up o r This includes licensed professio nals
an external physician, other d ifferent specialty o r subspecialty, who are practicing independently.
QHP, facility, o r o r a unique entity.
The ind ividual may also be a
health care o rganizatio n. Review of all materials fro m any facility o r o rganizatio nal
unique so urce co unts as o ne element provider such as fro m a hospital,
toward MDM. nursing facility, o r ho me health
care agency.
Clarifying reporting of tests – Unique Test
Question Answer
If my health system uses a single EMR and

I as a primary care physician review 3
notes from the cardiology group in my It is one unique document as it is a series
system that were since my last visit, is it: from one group. The intent of unique
one unique document because it is the source is to use the same group/same
same group, three because it is 3 items I specialty concept.
have not counted before or none because
we are all using the same source?
Data Complexity
Category 1: Tests and documents, Cont.,

❑Review of the result(s) of each unique test*;
• Tests are imaging, laboratory, psychometric, or physiologic data. A
unique test is defined by the CPT® code set (81002, 93000)
• Tests that are ordered outside of an encounter may be counted in the
encounter in which they are analyzed. In the case of a recurring
order, each new result may be counted in the encounter in which it is
analyzed.
❑Ordering of each unique test*
Tests ordered are presumed to be analyzed when the results are
reported. Therefore, when they are ordered during an encounter,
they are counted in that encounter. The review of the test at a
subsequent encounter does not count during that second encounter.
*Includes tests considered but not executed.
*CPT Assistant Nov 2020, pg. 5
Reporting of tests – Independent interpretation & ordered/reviewed
Question Answer
Based on the E/M office visit guidelines,

when a physician in a group practice orders If the test (in this case the X-ray) is being
and performs a diagnostic x-ray, including separately reported by the physician who is
interpretation and report of the resulting also reporting the E/M service, the order/
image, and subsequently submits a claim review of the test may not be used as an
for that, is it appropriate to count " MDM data element for selection of the E/M
Ordering of Each Unique Test" but not level of service. A chest x-ray requires an
“Review of the Results of Each Unique Test” interpretation and is not a “result” only
when determining Data in MDM? study
Clarifying Reporting of Tests
Amount and/or Complexity of Data to be Reviewed and Analyzed
Analyzed: Analyzed is a term describing the process of using the data as part of the MDM. The data
element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought
processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the
results are reported. Therefore, when they are ordered during an encounter, they are counted in that
encounter. Tests that are ordered outside of an encounter may be counted in the encounter where they
are analyzed. In the case of a recurring order, each new result may be counted in the encounter at
which it is analyzed.
For example, an encounter that includes an order for monthly prothrombin times would count for one
prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent
encounter, may be counted as a single test in that subsequent encounter. Any service for which the
professional component is separately reported by the physician or other qualified health care
professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or
independently interpreted for the purposes of determining the level of MDM
Analysing Clarified
Data Complexity
Category 1 and/or 2: Assessment requiring an independent historian(s)

Category 1 and/or 2: Assessment requiring an independent historian(s)
❑An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history
in addition to a history provided by the patient who is unable to provide a complete or reliable
history (e.g., due to developmental stage, dementia, or psychosis) or because a
confirmatory history is judged to be necessary.
• In the case where there may be conflict or poor communication between multiple historians
and more than one historian is needed, the independent historian requirement is met. It does
not include translation services. The independent history does not need to be obtained in
person
Or
Category 2: Independent interpretation of tests

Category 2: Independent
❑The interpretation interpretation
of a test for which there ofantests
is a CPT® code, and interpretation or report is
customary. This does not apply when the physician or other QHP who reports the E/M service is
reporting or has previously reported the test. A form of interpretation should be documented
but need not conform to the usual standards of a complete report for the test.
Data Complexity
Category 3: Discussion of management or
test interpretation
Discussion of management or test interpretation with external
physician/other QHP\appropriate source (not separately

reported)
•
Discussion requires an interactive exchange. The exchange
must be direct and not through intermediaries (e.g.,
clinical staff or trainees).
•
Sending chart notes or written exchanges that are within
progress notes does not qualify as an interactive exchange.
The discussion does not need to be on the date of the
encounter, but it is counted only once and only when it is
used in the decision making of the encounter.
•
It may be asynchronous (i.e., does not need to be in person),
but it must be initiated and completed within a short time
period (e.g., within a day or two).
•
A combination of different data elements, for example, a combination of notes reviewed, tests ordered,
tests reviewed, or independent historian, allows these elements to be summed. It does not require each
item type or category to be represented. A unique test ordered, plus a note reviewed and an independent
historian would be a combination of three elements.
•
Of course, an interpreter should not be considered an independent historian as they are simply relaying
information presented by the patient.

A form of interpretation should be documented but need not conform to the usual standards of a complete report
for the test.
Chief Complaint: Est Patient here for follow-up Diabetes and Hypertension Patient presents today
for his 6-month follow-up to review his Type 2 DM and
Hypertension. His DM has been controlled on Metformin for 2 years. His HTN is controlled
with metoprolol, started 6 months ago. Patient checks BS and B/P daily and reports WNL. No
other s/s to report today.
CMP and HbA1C lab tests ordered.
B/P 130/80 EKG performed today, normal sinus rhythm.
Patients' wife states he had an abnormal diabetic eye exam recently but can not remember what
the ophthalmologist said. The report is not in the chart. I spoke with Dr. Smith (ophthalmologist)
and he advised that he saw some mild changes in the retina and has arranged to follow up with
the patient.
Amount/Complexity of Data Reviewed & Analyzed - Example
E X A M PL E
Category 1: Tests and documents

Any combination of 3 from the following:
•Review of prior external note(s) from each unique source*;

•review of the result(s) of each unique test*;
•ordering of each unique test*
•Assessment requiring an independent historian(s)
or
Category 2: Independent interpretation of tests
•Independent interpretation of a test performed by another
physician/other QHP (not separately reported);
or
2. Ordered CMP
1. Category 3: Discussion of management or test interpretation
Ordered HgA1c
3. Wife Stated patient saw •Discussion of management or test interpretation with
Ophthalmologist for eye issue external physician/other QHP/appropriate source (not
4. Spoke with Ophthalmologist separately reported)
patient has mild retinopathy
Data – High
Complexity
Risk of Complication and/or Morbidity or Mortality of Patient MGT
Definition of Risk
• Counseling
• Diet and Exercise
• EKGs and EEGs
• Rest
• Superficial bandages and
dressings
Minimal - • Urinalysis
• Ultrasounds, Echocardiogram
Risk
Risk factors are those that are relevant to the patient and procedure.
 Chest x-rays,
 CT/MRI w/o contrast
 IV fluids w/o additives
 Lab tests requiring
venipuncture
Low - Risk  Minor surgery w/o risk factors
 Over the counter drugs
 Therapies (PT/OT, etc.)
• Prescription drug management

• Decision regarding minor surgery w/
identified patient or procedure risk
factors
• Decision regarding elective major
surgery w/o identified patient or
procedure risk factors
Moderate - • Diagnosis or treatment significantly
Risk limited by social determinants of health
Examples of SDH Codes

Z56.3 Stressful work schedule
Z55.0 Illiteracy and low‐level literacy
Z57.6 Occupational exposure to extreme temperature
Z59.0 Homelessness
Z59.4 Lack of adequate food and safe drinking water
Z59.5 Extreme poverty
Z59.7 Insufficient social insurance and welfare support
Z60.2 Problems related to living alone
Z62.21 Child in welfare custody
Z63.31 Absence of family member due to military
deployment
Z64.0 Problems related to unwanted pregnancy
Z65.2 Problems related to release from prison
• Drug therapy requiring intensive monitoring

for toxicity
• Decision regarding elective major surgery w/
identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization or escalation
of hospital level care
High - Risk • Decision not to resuscitate or to deescalate care
because of poor prognosis
Drug Therapy with Intensive Monitoring for Toxicity
A therapeutic agent which has the potential to cause serious morbidity or death
Monitoring is performed for assessment of potential adverse effects, not primarily

for assessment of the therapeutic effect
Monitoring should follow practice that is generally accepted for the drug but may
be patient specific in some cases.
Intensive monitoring may be long-term or short term. Long-term intensive

monitoring is performed not less than quarterly.
Monitoring may include a lab test, a physiologic test or imaging
• Monitoring by history or examination does not qualify. The monitoring affects

the level of medical decision making in a visit in which it is considered in the
management of the patient.
If a provider considers a
treatment but chooses to not
The 2021 guidelines make it Patient non-compliance select that treatment,
clear that options considered, (Z91.19) may add to risk, documentation should
but not selected. providers should document support the reason why,
how. such as patient refusal,
patient is not a surgical
candidate, etc.
And
And /or
/or
Auditing Based on Time
Time is based on the total

time (both face-to-face and non-face-to-face) personally spent by the
physician or NPP on E/M services on the date of the encounter.
•
Start and stop times are not required to be documented.
•
Providers should not list a range of time. When using time to level an
•
CPT® : “The appropriate time should be documented in the medical record when E/M, the time statement must be
it is used as the basis for code selection.” documented by provider within
•
If time is not documented, or is an insufficient time for the minimum code, MDM the note and must state their
must be used to level the encounter. best estimate of the exact time
spent in care of the patient on
the date of the encounter.
Shared or Split Visit Time
Add time spent by reporting provider who is

assessing and managing patient.
Only distinct time should be summed.
When two or more individuals jointly meet with or
discuss the patient, only the time of one individual
should be counted.
Total Time Activities
Physician or other qualified health care professional time includes the following activities, when
performed:
 preparing to see the patient (eg, review of tests)
 obtaining and/or reviewing 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 record
 independently interpreting results (not separately reported) and communicating results to
the patient/family/caregiver
 care coordination (not separately reported)◄
Do not count time spent on the following:

 The performance of other services that are reported separately
 Travel
 Teaching that is general and not limited to discussion that is required for the management of a
specific patient
Time
Time Activities
Provider Activities Time Spent (Minutes)
Pre-Visit
Preparing to see the patient (e.g., review of tests, reviewing notes, results, 2
correspondence, reports) (Note sources, dates)
Visit
Obtaining and/or reviewing separately obtained history (Note sources) 2
Performing a medically appropriate examination and/or evaluation 5
Counseling and educating the patient/family/caregiver 1
Referring and communicating with other health care professionals (when
not separately reported)
Post-Visit
Documenting clinical information in the electronic or other health record 5
Independent interpretation of tests (not separately billed) and
communicating results to the patient/ family/caregiver
Care Coordination (not separately billed)
TOTAL TIME ON DOS 15
Time Based Coding
Time Calculation
AMA Time Calculation
New Patient Established

Patient
1 5 m i n utes us e
99202 99212 If <
M DM
15-29 mins 10-19 mins
99203 99213
30-44 mins 20-29 mins
99204 99214
45-59 mins 30-39 mins
99205 99215
60-74 mins 40-54 mins
Prolonged Services
C h a ng es
2 0 2 3 o m i ng CMS
C
CPT® 99417 NEW CPT® 993X0 G2212
q Prolonged office or other q Prolonged IP or q Prolonged office or other

OP E/M service(s) observation E/M service(s) OP E/M service(s)
q Each 15 min of total time q Each 15 minutes of total q Beyond each additional
(List separately in time (List separately in 15 min of total time (List
addition to codes 99205, addition to the code (Use separately in addition to
99215,99245, 99345,99350, 993X0 in conjunction CPT® codes 99205, 99215
99483) with99223,99233,99236, for office or other
99255,99306, 99310) outpatient E/M)
q Proposing 3 new
prolonged HCPCS codes.
Prolonged Services – CMS & AMA
Use code 99417 to report prolonged total time provided by the physician or QHP on the date of an office or other
outpatient services, office consultation, or other outpatient (home, residence) E/M service, contact beyond the
required time of the primary service when the primary service level has been selected using total time, each 15
minutes of total:
Additional CPT notes with 99417:
list separately in addition to CPT® codes (Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483)
Do not report 99417 for any time unit less than 15 min
Do not report 99417 on the same date of service as 90833, 90836, 90838, 99358,99359, 99415, 99416.
For prolonged services on a date other than the date of a face-to-face evaluation and management encounter with
the patient and/or family/caregiver, see 99358, 99359.
Total time is the sum of all time, with and without direct patient contact and including prolonged
time, spent by the reporting practitioner on the date of service of the visit.
99417 may not be used with psychotherapy services.

Prolonged Services
Prolonged Services
Use code 993X0 to report prolonged total time provided by the physician or GXXX3
QHP on the date of an inpatient (Nursing Facility, Observation or IP Consultation) E/M service, contact beyond
the required time of the primary service when the primary service level has been selected using total time,
each 15 minutes of total:
list separately in addition to CPT® codes 99223, 99233, 99236, 99255, 99306, 99310
Do not report 993X0 for any time unit less than 15 min
Do not report 993X0 on the same date of service as 90833, 90836, 90838, 99358, 99359)
For prolonged services on a date other than the date of a face-to-face evaluation and management
encounter with the patient and/or family/caregiver, see 99358, 99359.
*
Total time is the sum of all time, with and without direct patient contact and
including prolonged time, spent by the reporting practitioner on the date of service
of the visit.
Prolonged Services – 99358 & 99359 Codes
Total Duration of Prolonged Code(s)
Code(s) Services without
direct face-to-face Contact Codes 99358 and 99359 are used when a
Less than 30 minutes Not reported separately prolonged service in relation to a face-to-face
evaluation and management encounter with the
30-74 minutes 99358 X 1 patient and/or family/caregiver is provided on a
75-104 minutes 99358 X 1 and 99359 x 1 date other than the date of the E/M, whether
time was used to select the level of the face-to-face
105 or more minutes 99358 x 1 and 99358 x 2 or service.
more for each additional 30
minutes
Code Description  Prolonged service without direct patient contact may only
99358 Prolonged evaluation and management be reported when it occurs on a date other than the date
service before and/or after direct patient of the evaluation and management service.
care; first hour  For example, extensive record review may relate to a
previous evaluation and management service performed
+99359 Prolonged evaluation and management at an earlier date.
service before and/or after direct patient  However, it must relate to a service or patient which (face-
care; each additional 30 minutes. to-face) patient care has occurred or will occur and relate
to ongoing patient management.
Prolonged Services
99354, 99355 have been deleted.
• For prolonged evaluation and management services on the date of an

outpatient service, home or residence service, or cognitive assessment and
care plan, use 99417.
99356, 99357 have been deleted.
• For prolonged evaluation and management services on the date of an

inpatient or observation or nursing facility service, use 993X0, a new
code to be released during the official CPT® update.
Prolonged Service – Clinical Staff
• Codes 99415, 99416 are used when an evaluation and management (E/M) service is provided in the office or
outpatient setting that involves prolonged clinical staff face-to-face time with the patient and/or family/caregiver.
• The physician or other QHP is present to provide direct supervision of the clinical staff. This service is reported in
addition to the designated E/M services and any other services provided at the same session as E/M services.
• Time spent performing separately reported services other than the E/M service is not counted toward the
prolonged services time.
• Codes 99415, 99416 may be reported for no more than two simultaneous patients and the time reported is the time
devoted only to a single patient.
• Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during
an evaluation and management service in the office or outpatient setting, direct patient contact with physician
supervision.
Code Description
99415 First hour
+99416 each additional 30 minutes
Prolonged Service – Clinical Staff
The starting point for 99415 is 30 minutes beyond the typical clinical staff time for ongoing assessment of
the patient during the office visit. The Reporting Prolonged Clinical Staff Timetable provides the typical
clinical staff times for the office or other outpatient primary codes, the range of time beyond the clinical
staff time for which 99415 may be reported, and the starting point at which 99416 may be reported.
Place of Service – Initial Hospital OR Observation
 The following codes are used to report the first hospital inpatient (21) or observation (22)
status encounter with the patient.
 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 MDM
Initial History & Exam MDM Time*

99221 Medical Appropriate History and/or Straightforward or Low 40
examination
Medical Appropriate History and/or
99222 examination Moderate 55

99223 examination High 75
993X0 90+
Prolonged (993X0) 90 minutes or longer

Place of Service – Subsequent Hospital OR Observation
• The following codes are used to report the subsequent hospital (21) inpatient or
observation (22) status encounter with the patient.
• Subsequent 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 MDM
Subsequent History & Exam MDM Time*

99231 examination Straightforward or Low 25
993X0 65+
Prolonged (993X0) 65 minutes or longer

Place of Service – Initial & Subsequent Observation
Hospital Observation Services have been deleted.
Place of Service – Same day admit & Discharge
• For a patient admitted and discharged from hospital inpatient (21) or observation (22) status on the
same date, for the evaluation and management of a patient including admission and discharge on
the same date, which requires a medically appropriate history and/or examination and MDM.
• Two separate entries are required to document the admission and subsequent discharge including
the final examination of the patient, discussion of the hospital stay, instructions for continuing
care to all relevant caregivers, and preparation of discharge records, prescriptions, and
referral forms.
Same Day History & Exam MDM Time*

Admit/DC

99234 examination Straightforward or Low 45


993X0 100+
Discharge Codes
• The hospital inpatient (21) and observation (22) discharge day management codes are used
to report the total time (does not need to be continuous) spent by the physician or QHP who
is responsible for discharge services, on the day of the final discharge of the patient.
• The codes include, as appropriate, final examination of the patient, discussion of the
hospital stay, instructions for continuing care to all relevant caregivers, and preparation
of discharge records, prescriptions, and referral forms.
Discharge Documentation Time
Final examination, discussion hospital stay,

99238 instructions for continuing care, preparation of 30 minutes or less
discharge records, RX and referrals
Final examination, discussion hospital stay,

99239 instructions for continuing care, preparation of More than 30 minutes
discharge records, RX and referrals
Place of Service - Consultation
Consultation service require a request from Request

another physician or QHP to recommend care
for a specific condition or problem.
The consulting provider’s opinion and any
services that were ordered or performed must Recommendation
be communicated in written report to the
requesting physician or QHP.
Report
Outpatient Consultation Codes
The following codes may be used to report consultations that are provided in the office
(11) or other outpatient site (19/22), including the home or residence (12/13), or emergency
department (23).
Outpatient History & Exam MDM Time*
99242 Medical Appropriate History and/or Straightforward 20

examination
99243 Medical Appropriate History and/or Low 30
examination
99417 70+
Medicare does
NOT cover
consultations
Inpatient Consultation Codes
The following codes should be used to report consultations reported in hospital inpatients (21), observation-level
patients (22), residents of nursing facilities (31/32), or patients in a partial hospital setting, and when the
patient has not received any face-to-face professional services from the physician or other QHP or another
physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice
during the stay.
If a consultation is performed in anticipation of, or related to, an admission by another physician or other QHP,
and then the same consultant performs an encounter once the patient is admitted by the other physician or other
QHP, report the consultant’s inpatient encounter with the appropriate subsequent care code (99231, 99232, 99233).
Inpatient History & Exam MDM Time*

examination
99253 Medical Appropriate History and/or Low 45

examination
99254 Medical Appropriate History and/or Moderate 60

examination
99255 Medical Appropriate History and/or High 80

examination
993X0 95+
Emergency Department Codes
• An emergency department (23) is defined as an organized hospital-based facility for
the provision of unscheduled episodic services to patients who present for immediate
medical attention. The facility must be available 24 hours a day.
• Time is not a descriptive component for the emergency department levels of E/M
services because emergency department services are typically provided on a
variable intensity basis, often involving multiple encounters with several patients
over an extended period of time.
• May be used by physicians and QHPs other than just the ED staff.
ED History & Exam MDM

Evaluation and management of a patient that may not
99281 require the presence of a physician or other qualified _
healthcare provider
99282 Medical Appropriate History and/or examination Straightforward
99283 Medical Appropriate History and/or examination Low
99284 Medical Appropriate History and/or examination Moderate
99285 Medical Appropriate History and/or examination High
Incident to & Split & Shared Services
99211 (Office and other Incident-To guidelines

Outpatient) does not require May not require the apply there must be an order for
presence of the physician or

MDM level other QHP, but the service is the service, and the supervising

Total time spent provided under the physician’s physician or NPP (or one from
Presenting problem(s) no or other QHP’s supervision. the same group) must be within
requirement

the office suite and immediately

available if needed.
99281 (Emergency May not require the Split/Shared Visit a visit in

Department) does not require presence of the physician or which a physician and other
MDM level other QHP, but the service is QHP(s) jointly provide the

Total time spent provided under the physician’s face-to-face and non-face-to-

Presenting problem(s) no or other QHP’s supervision. face work related to the visit.
requirement

Initial Nursing Facility Care
NEW HIGH PROBLEM:
Multiple morbidities requiring intensive management
• A set of conditions, syndromes, or functional impairments that are likely to

require frequent medication changes or other treatment changes and/or re-
evaluations. The patient is at significant risk of worsening medical (including
behavioral) status and risk for (re)admission to a hospital.
Initial Nursing Facility Care
• These codes should also be used to report evaluation and management services
provided to a patient in nursing facilities (32), skill nursing facilities (31), a
psychiatric residential treatment center (56) and immediate care facility for
individuals with intellectual disabilities (54).
• Regulations pertaining to the care of nursing facility residents govern the nature
and minimum frequency of assessments and visits. These regulations also govern
who may perform the initial comprehensive visit.
• Modifiers may be required to identify the principal physician from specialist
performing consultations or concurrent care.
Initial History & Exam MDM Time*

Medical Appropriate History and/or Straightforward or
99304 examination Low 35
993X0 _ _ 60+
Subsequent Nursing Facility Care
•
The following codes are used to report the subsequent nursing facilities and
skilled nursing facilities encounter with the patient.
•
Subsequent nursing facility care, per day, for the evaluation and management
of a patient, which requires a medically appropriate history and/or
examination
•
Use subsequent visit when the principal physician’s team member performs care
before the required comprehensive assessment.
Subsequent History & Exam MDM Time*
examination
99308 examination Low 15
993X0 _ _ 60+
(99318 Annual NF Assessment has been deleted. To report, see 99307, 99308, 99309,
99310)
Discharge Codes - Nursing Facility Care
•
The nursing facility discharge management codes are to be used to report the total
duration of time spent by a physician or other QHP for the final nursing facility
discharge of a patient
•
The codes include, as appropriate, final examination of the patient, discussion of the
hospital stay, instructions for continuing care to all relevant caregivers, and
preparation of discharge records, prescriptions, and referral forms.
•
These services require a face-to-face encounter with the patient and/or family/
caregiver that may be performed on a date prior to the date the patient leaves the
facility. Code selection is based on the total time on the date of the discharge
management face-to-face encounter
New Patient – Home or Residence Service
•
The following codes are used to report evaluation and management services provided in
a home or residence (12) to a new patient, which requires a medically appropriate
history and/or examination MDM.
•
Home may be defined as a private residence, temporary lodging, or short-term
accommodation (e.g., hotel, campground, hostel, or cruise ship). These codes are also
used when the residence is an assisted living facility (13), group home (14) (that is not
licensed as an intermediate care facility for individuals with intellectual disabilities),
custodial care facility (33) or residential substance abuse treatment facility (55).
•
99324, 99325, 99326, 99327, 99328 have been deleted.
Prolonged (99417) 90 minutes or longer

Established Patient - Home or Residence Service

The following codes are used to report evaluation and management services provided
in a home or residence to an established patient.

(99334, 99335, 99336, 99337 have been deleted. For domiciliary, rest home [eg,
boarding home], or custodial care services, established patient, see home or
residence services codes 99347, 99348, 99349, 99350)
These codes are also used when the residence is an assisted living facility (13), group
home (14) (that is not licensed as an intermediate care facility for individuals with
intellectual disabilities), custodial care facility (33), or residential substance abuse
treatment facility (55).
Prolonged (99417) 75 minutes or longer

References
• AMA E/M 2023:

• https://onl inexp eriences.com/scripts/Server.nxp?LASCmd=AI:1;F:LBSATTACH!V&AttachmentKey=8655664
• CPT® Evaluation and Management (E/M) Code and Guidel ine Changes https://www.ama-assn.org/system/fi les/2023-e-m-descriptors-g uidel ines.p df
• New office and other O utp atient 2021 MDM Table https://www.ama-assn.org/system/fi les/2019-06/cpt-revised-mdm-g rid.p df
• AMA Guide for 2021 E/M Changes https://www.ama-assn.org/system/fi les/2019-06/cpt-office-p rolonged-svs-code-changes.p df https://www.cms.gov/newsroom/
fact-sheets/final-p ol icy-p ayment-and-qual ity-p rovisions-changes-medicare-p hysic ian-fee-schedule-calendar-year-1
• CMS E/M Services Guide https://www.cms.gov/outreach-and-
education/medicare-learning-network-ml n/ml np roducts/downloads/eval-mg mt-serv-g uide-icn006764.p df
• M LN on Final Rules
https://www.cms.gov/O utreach-and-Education/O utreach/N PC/Downloads/2019-11-06-ASC-Presentation.p df https://www.cms.gov/fi les/document/12120-pfs-
final-rule.p df
• https://www.cms.gov/newsroom/fact-sheets/p rop osed-p ol icy-p ayment-and-qual ity-p rovisions-changes-medicare-p hysic ian-fee-schedule-calendar-year-2
• Medicare Claims Processing Manual Ch 12 https://www.cms.gov/Reg ulations-and-g uidance/Guidanc E/Manuals/Downloads/c l m104c12.p df

Aalc Enm Update 2023

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2023 Evaluation &

Management Updates (AMA

Nurse Practitioners and

Acute, Uncomplicated Illness or Injury

Stable, acute illness

Elements of Medical Decision Making

❑1 or more chronic illnesses with exacerbation, progression, or side effects of

Elements of Medical Decision Making

• The complexity of the presenting problem, TODAY. For example,

• Nature of the condition.

• Symptoms that may cluster around a

• The ordering and actual performance and/or interpretation of diagnostic test/

Category 1: Tests and documents

An external physician o r other QHP

If my health system uses a single EMR and

Category 1: Tests and documents, Cont.,

Based on the E/M office visit guidelines,

Amount and/or Complexity of Data to be Reviewed and Analyzed

Category 1 and/or 2: Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

Category 1: Tests and documents

•Review of prior external note(s) from each unique source*;

• Prescription drug management

Examples of SDH Codes

• Drug therapy requiring intensive monitoring

Monitoring is performed for assessment of potential adverse effects, not primarily

Intensive monitoring may be long-term or short term. Long-term intensive

Monitoring may include a lab test, a physiologic test or imaging

• Monitoring by history or examination does not qualify. The monitoring affects

Time is based on the total

Add time spent by reporting provider who is

Do not count time spent on the following:

New Patient Established

CPT® 99417 NEW CPT® 993X0 G2212

q Prolonged office or other q Prolonged IP or q Prolonged office or other

99417 may not be used with psychotherapy services.

99354, 99355 have been deleted.

• For prolonged evaluation and management services on the date of an

99356, 99357 have been deleted.

• For prolonged evaluation and management services on the date of an

Initial History & Exam MDM Time*

Medical Appropriate History and/or

Prolonged (993X0) 90 minutes or longer

Subsequent History & Exam MDM Time*

Prolonged (993X0) 65 minutes or longer

Same Day History & Exam MDM Time*

Medical Appropriate History and/or

Medical Appropriate History and/or

Medical Appropriate History and/or

Discharge Documentation Time

Final examination, discussion hospital stay,

Final examination, discussion hospital stay,

Consultation service require a request from Request

Outpatient History & Exam MDM Time*

99242 Medical Appropriate History and/or Straightforward 20

Inpatient History & Exam MDM Time*

99253 Medical Appropriate History and/or Low 45

99254 Medical Appropriate History and/or Moderate 60

99255 Medical Appropriate History and/or High 80

ED History & Exam MDM

99211 (Office and other Incident-To guidelines

the office suite and immediately

99281 (Emergency May not require the Split/Shared Visit a visit in