Evaluation and Management Update - 2023

Presented by:
Sharon, M.Sc, CPC
Trainer-Technical Training
Omega Healthcare Management Services Pvt Ltd

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 Disclaimer

This material 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 handout is intended as an educational guide and should
not be considered a legal/consulting opinion.

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 Objectives

 E/M Introductory Guidelines – Update and Consolidation

 Hospital Observation Services – Deletion

 Hospital Inpatient and Observation Care Services – Revision

 Consultations E/M Codes – Deletion and Revision

 Emergency Department Services – Revision

 Nursing Facility Services – Deletion and Revision

 Domiciliary, Rest Home (E.G., Boarding Home), or Custodial Care Services – Deletion

 Home or Residence Services – Deletion and Revision

 Prolonged Services – New Code, Deletion and Revision

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 Key Components

Current year- History, Exam and MDM

MDM- Retained for 2023 History and Exam – Removed for 2023
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 Key Differences-Current Guidelines vs E/M 2023 Guidelines

PLACE OF SERVICE CURRENT GUIDELINE 2023 GUIDELINE

Emergency Department History, Exam and MDM MDM
Inpatient History, Exam and MDM or Time MDM or Time
Observation History, Exam and MDM or Time Deleted (Inpatient reported instead)
Consultation History, Exam and MDM or Time MDM or Time
Nursing facility History, Exam and MDM or Time MDM or Time
Home or Residence History, Exam and MDM or Time MDM or Time
Domiciliary and Rest Home History, Exam and MDM or Time Deleted (Home codes reported instead)
Prolonged Service History, Exam and MDM or Time MDM or Time

PLACE OF SERVICE CURRENT GUIDELINE 2023 GUIDELINE

Office or Other outpatient MDM or Time MDM or Time
Preventive Services Payer and Patient Age Payer and/or Patient Age
Critical Care Time Time

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 Highlights - E/M 2023 Updates
 AMA has released changes to CPT E/M codes and guidelines, set to go into effective Jan 1, 2023
Changes are build on revisions to office/outpatient E/M codes in 2021 that emphasized MDM and
sought to reduce documentation burden
E/M changes will affect hospital inpatients, observations, consultations, ER, nursing facilities and
home, rest home, and domiciliary E/M codes
Level of E/M services will be based MDM as defined for each service or total time for E/M
service performed on date of encounter. History and exam no longer used to select level of code
Changes to prolonged services codes. CMS proposed prolonged services codes
Created new coding guidelines for reporting multiple E/M services on same day
Minor editorial revisions in MDM table to incorporate several clarifications related to IP hospital
care

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 Why the Updates?

 To decrease administrative burden of documentation and coding, and align CPT and CMS whenever
possible

 To decrease the need for audits

 To decrease unnecessary documentation in the medical

record that is not needed for patient care crease
unnecessary documentation in the medical record that is
not needed for patient care

 To ensure that payment for E/M is resource-based and that

there is no direct goal for payment redistribution between
specialties
 E/M Categories and Subcategories -2023
Office and /or Preventive Emergency Inpatient and Consultations Nursing facility Home or
Outpatient Services Department Observations Residence

Sick visits Comprehensive Emergency care Hospital care Outpatient Nursing Care Home or
services Residence care

99202- 99205 99381-99397 99281- 99285 99221-99239 99242-99245 99304-99316 99341-99350

Prolonged Prolonged Prolonged

Services IPPE Critical care Critical care Inpatient services services

99415- 99417 G0402 99291-99292 99291-99292 99252-99255 99418, G0317 99417, G0318

Prolonged Newborn or
G2212 AWV services Pediatric care

99354-99355 G0438- G0439 99415-99417 99468-99476

Prolonged
services

99418, G0316

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 Medical Decision Making- MDM
 Medical Decision Making: the process by which a diagnosis or treatment plan formulated from available
medical information, often with incorporation of known patient preferences

 MDM is defined by three elements:

• The number and complexity of problem(s) that are addressed during the encounter

• The amount and/or complexity of data to be reviewed and analyzed

• The risk of complications and/or morbidity or mortality of patient management

 To qualify for a particular level of MDM, two of the three elements for that level of MDM must be met
or exceeded

 Four types of MDM levels: straightforward, low, moderate and high

 The concept of the level of MDM does not apply to 99211, 99281

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Evaluation and Management Update - 2023

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Evaluation and Management Update - 2023

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 Newly Added Definitions for MDM

Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The
patient is improved and, while resolution may not be complete, is stable with respect to this condition
E.g.- Influenza, treatment previously started & condition improving, no fever or lung involvement
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent
or new short-term problem with low risk of morbidity for which treatment is required. There is little to
no risk of mortality with treatment, and full recovery without functional impairment is expected. The
treatment required is delivered in a hospital inpatient or observation level setting
E.g. - Head injury with LOC required further observation and admitted to observation care

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 Newly Added Definitions for MDM

Decision regarding hospitalization or escalation of hospital- level care: (admit, transfer, ICU) the
decision to hospitalize applies to the outpatient or nursing facility encounters. Transfer to another facility
also constitutes hospitalization or escalation of care. Observation, SNF, rehab, and to send patient to the
ER for office/outpatients, etc. Also includes the decision not to hospitalize after initial consideration of
hospitalization. The decision to escalate hospital level of care (e.g., Transfer to ICU) applies to the
hospitalized or observation care patient
E.g. - Patient with chest pain diagnosed with heart attack and admitted to ICU
Parenteral controlled substance: (narcotic and psychotropic) is generally a drug or chemical whose
manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription
medications that are designated by law
E.g.- Morphine, Phenobarbital, Diazepam and Estazolam

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Emergency Department Services E/M Codes Current vs 2023 CPT Description

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 Hospital Observation and Inpatient Hospital Services
 Deletion - 99217-99220 and 99224- 99226

 Revision - 99221-99223, 99221-99233, 99238-99239

 Retention - 99234 – 99236

 When patient is admitted to hospital as IP/OB status in the course of an encounter in another site of
service (e.g., hospital ER, office, nursing facility), services in initial site may be separately reported
 Modifier 25 may be added to other E/M service to indicate a significant, separately identifiable service
by same physician or other qualified health care professional was performed on same date
 CMS proposes to retain policy of only reporting one E/M service per calendar date

 For the purpose of reporting initial hospital IP/OB care service, a transition from OB level to IP does not
constitute a new stay

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 Hospital Observation and Inpatient Hospital Services
 In case when services in separate site are reported and initial IP/OB care is a consultation
service, do not report 99221-99223, 99252-99255
 The consultant reports subsequent hospital IP/OB care codes 99231-99233 for second
service on same date
 If 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 (99231-99233)
 This instruction applies whether the consultation occurred on date of admission or date
previous to admission. It also applies for consultations reported with any appropriate code
(e.g., Office or other outpatient visit or office or other outpatient consultation)

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 Hospital Observation and Inpatient Hospital Services

 Discharge day management codes are reported with total duration of time on date of encounter spent by a
physician or other QHP for final hospital or observation discharge of a patient, even if time spent by physician or
other QHP on that date is not continuous
 Total time on date of the encounter is by calendar date
 When using MDM or total time for code selection, a continuous service that spans the transition of two calendar
dates is a single service and is reported on one calendar date
 If the service is continuous before and through midnight, all the time may be applied to the reported date of
service
 Modifier – AI (principal physician of record) should be appended to the initial visit submitted by the admitting
provider to identify the physician who oversees the patient’s care from all other physicians who may be furnishing
specialty care

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 Hospital Observation and inpatient Hospital Services
< 8 Hours 8 to 24 hours > 24 hours

99221 - 99223 99234 - 99236 Hospital Care Consultations Critical care

Prolonged services Initial 99252- 99255 < 6 years > 6years

Prolonged
+99418, G0316 99221 - 99223 New born 0 -28 days 99291 - 99292
services

Subsequent +99418 99468 - 99469

Pediatrics –
99231 - 99233 29 days – 24 months

Discharge 99471 - 99472

99238 - 99239 Pediatrics - 2 -5 years

Prolonged services 99475 - 99476

+99418, G0316

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Current vs 2023 CPT Description – Initial Hospital Care

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Current vs 2023 CPT description – Subsequent Hospital Care

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Current vs 2023 CPT Description – Including Admission and Discharge Care

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 Consultations

Revision and retention- 99242- 99245, 99252 -99252

Deletion- 99241 and 99251- to align with four levels of MDM
Certain guidelines deemed confusing by the AMA have been deleted, including the
definition of “transfer of care”
The CMS states, “the intent of a consultation service is that a physician is asking
another physician for advice, an opinion, recommendation, suggestion, direction,
counsel, etc., In evaluating or treating a patient because that individual has expertise in
a specific medical area beyond the requesting professional’s knowledge”
Consultations codes are not accepted from Medicare since 2010
Few private carriers accept consultation codes and it is important for practices to verify
with the carrier on their billing guidelines

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 Initial vs Subsequent Consultation

Follow-up visits in the consultant’s office or other outpatient facility that are initiated by the
consultant or patient are reported using the appropriate codes for established patients in the office
(99212-99215) or home or residence (99347-99350)
Only one consultation may be reported by a consultant per admission
Subsequent consultation services during the same admission are reported using subsequent
inpatient or observation hospital care codes (99231-99233) or subsequent nursing facility care codes
(99307-99310)

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 Initial vs Subsequent Care

•Initial Care: An initial service may be reported when the patient has NOT received any professional
services from the physician or other QHP or another physician or other QHP of the exact same
specialty and subspecialty who belongs to same group practice during the stay
•Subsequent Care: A subsequent service may be reported when the patient has received any
professional services from physician or other QHP or another physician or other QHP of the exact
same specialty and subspecialty who belongs to same group practice during the stay

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Current vs 2023 CPT Description – Office and Outpatient Consultation

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Current vs 2023 CPT Description – Inpatient Consultation

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 Nursing Facility Services

Nursing facility guidelines is revised with a new “problem addressed” definition of “multiple
morbidities requiring intensive management,” to be considered at the high level for initial nursing
facility care
Code 99318 (annual nursing facility assessment) is deleted. This service will be reported using codes
99307, 99308, 99309, and 99310 (subsequent nursing facility care services) or Medicare G codes
When the principal physician’s team member performs care before the required comprehensive
assessment, using subsequent visit is allowed

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Current vs 2023 CPT Description – Initial Nursing Facility

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Current vs 2023 CPT Description – Subsequent Nursing Facility

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 Home or Residence Services

 Revision- 99341, 99342, 99344, 99345, 99347-99350 and guidelines

 Deletion - 99334 through 99340, 99343

 When selecting code level using time, time spent on travelling is not included

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Current vs 2023 CPT Description – New Home or Residence Services

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Current s 2023 CPT Description – Established Home or Residence Services

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 Prolonged Services Codes- Office and Other Outpatient
•Deletion – 99354-99355
•Direct patient contact prolonged service codes (99354-99357) are deleted and these services will be reported
using code 99417 (office prolonged service)
•Codes 99358 and 99359 retained and used when a prolonged service is provided on a date other than date of a
face-to-face evaluation and management encounter with the patient and/or family/caregiver
•There is a difference between AMA and Medicare threshold time for reporting prolonged care
•AMA adds 15 minutes to minimum time of the highest level, but Medicare adds 15 minutes to maximum time
of highest level

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 AMA Prolonged Services Hospital Care - 2023

•Deletion – 99356-99357
•Direct patient contact prolonged service codes (99354-99357) are deleted and these services will be reported
using code 99418 inpatient prolonged service
99418 prolonged IP/OB evaluation and management service(s) time with or without direct patient contact
beyond required time of primary service when primary service level has been selected using total time, each 15
minutes of total time (list separately in addition to the code of the IP/OB E/M service) (list separately in addition
to the code of IP/OB evaluation and management service)
Use 99418 in conjunction with 99223, 99233, 99236, 99255, 99306, 99310
Do not report 99418 on same date of service as 90833, 90836, 90838, 99358, 99359
Do not report 99418 for any time unit less than 15 minutes

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 CMS Prolonged Services Hospital Care - 2023
G0316 prolonged hospital IP/ OB care evaluation and management service(s) beyond total time for
primary service (when primary service has been selected using time on date of the primary service);
each additional 15 minutes by physician or qualified healthcare professional, with or without direct
patient contact (list separately in addition to CPT codes 99223, 99233, and 99236 for hospital IP/OB care
E/M services)
G0317 prolonged nursing facility E/M service(s); each additional 15 minutes. (List separately in addition
to CPT codes 99306, 99310 for nursing facility E/M services)
G0318 prolonged home or residence E/M service(s); each additional 15 minutes. (List
separately in addition to CPT codes 99345, 99350 for home or residence E/M services)
Medicare has different threshold times to report prolonged services with primary E/M
services, which not exactly same as AMA

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 Prolonged Service Code for Hospital Care

INITIAL IP / OB
1 - 39 minutes 40 - 54 minutes 55 - 74 minutes > 75 minutes
Use MDM 99221 99223 MCR NON MCR
75 - 104 minutes 75 - 89 minutes
99223 99223
105 - 119 minutes 90 - 104 minutes
99223, G0316 99223, 99418
120 - 134 minutes 105 - 119 minutes
99223, G0316*2 99223, 99418*2

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 Prolonged Service Code for Hospital Care

SUBSEQUENT IP / OB
1 -24 minutes 25 -34 minutes 35 -49 minutes > 50 minutes
Use MDM 99231 99232 MCR NON MCR
50 - 79 minutes 50 - 64 minutes
99233 99233
80 - 94 minutes 65 - 79 minutes
99233, G0316 99233, 99418
95 - 109 minutes 80 - 94 minutes
99233, G0316*2 99233, 99418*2

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 Prolonged Service Code for Hospital Care

ADMISSION AND DISCHARGE SAME DAY

1 -44 minutes 45-69 minutes 70 -84 minutes > 85 minutes
USE MDM 99234 99235 MCR NON MCR
85 - 124 minutes 85 - 99 minutes
99236 99236
125 - 139 minutes 100 - 114 minutes
99236, g0316 99236, 99418
140 - 154 minutes 115 - 129 minutes
99236, G0316*2 99236, 99418*2

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 Prolonged Service Code for Consultation

OUTPATIENT CONSULTATIONS
1 - 19 minutes 20 - 29 minutes 30 - 39 minutes 40 - 54 minutes 55 - 69 minutes 70 - 94 minutes

Use MDM 99242 99243 99244 99245 99245, 99417

95 - 109 minutes

99245, 99417*2

INTPATIENT CONSULTATIONS
1 - 34 minutes 35 - 44 minutes 45 – 59 minutes 60 - 79 minutes 80 – 94 minutes 95 - 109 minutes

Use MDM 99252 99253 99254 99255 99255, 99418

110 - 124 minutes

99255, 99418*2

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 Prolonged Service Code for Nursing Facility

INITIAL NURSING FACILITY

1 - 24 minutes 25 - 34 minutes 35 - 44 minutes > 45 minutes

Use MDM 99304 99305 MCR NON MCR

45 - 94 minutes 45- 59 minutes

99306 99306
95 - 109 minutes 60 - 74 minutes

99310, G0317 99310, 99418

110 - 124 minutes 75 - 89 minutes

99310, G0317*2 99310, 99418*2

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 Prolonged Service Code for Nursing Facility

SUBSEQUENT NURSING FACILITY

1 - 9 minutes 10 - 14 minutes 15 - 29 minutes 30 - 44 minutes > 45 minutes

Use MDM 99307 99308 99309 MCR NON MCR

45 - 84 minutes 45 - 59 minutes

99310 99310

85 - 99 minutes 60 - 74 minutes

99310, G0317 99310, 99418

100 - 114 minutes 75 - 89 minutes

99310, G0317*2 99310, 99418*2

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 Prolonged Service Code for Home and Residence

NEW HOME AND RESIDENCE

1 - 14 minutes 15 - 29 minutes 30 - 59 minutes 60 - 74 minutes < 75 minutes

Use MDM 99341 99342 99344 MCR NON MCR

75 - 140 minutes
75 - 89 minutes

99345 99345
141 - 155 minutes 90 - 104 minutes

99345, G0318 99345, 99417

156 - 171 minutes 105 - 119 minutes

99345, G0318*2 99345, 99417*2

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 Prolonged Service Code for Home and Residence

ESTABLISHED HOME AND RESIDENCE

1 - 19 minutes 20 - 29 minutes 30 - 39 minutes 40 - 59 minutes < 60 minutes
Use MDM 99347 99348 99349 MCR NON MCR
60 – 111 minutes
60 - 74 minutes

99350 99350
112 - 126 minutes 75 - 140 minutes
99350, G0318 99350, 99417
127 - 141 minutes
141 - 155 minutes

99350, G0318*2 99350, 99417*2

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 Time Thresholds to Report Prolonged Services
Primary E/M Prolonged Prolonged Service Threshold Time to report Count Physician/NPP time
POS Service Codes Codes for Other Prolonged Services with spent with in this time
Service for Medicare than Medicare Primary E/M period
In-Patient or
99223 Initial ✚G0316 ✚99418 105 Minutes Date of Visit
Observation
In-Patient or 99233
Observation Subsequent ✚G0316 ✚99418 80 Minutes Date of Visit

In-Patient or
99236 SAAD ✚G0316 ✚99418 125 Minutes Date of Visit + 3 days after
Observation

Nursing Facilities 99306 Initial ✚G0317 ✚99418 95 Minutes 1 day before visit + Date of
Visit + 3 days after
99310 1 day before visit + Date of
Nursing Facilities ✚G0317 ✚99418 85 Minutes
Subsequent Visit + 3 days after
Home or 99345 New 3 days before visit + Date of
✚G0318 ✚99417 141 Minutes
Residence Patient Visit + 7 days after
99350
Home or 3 days before visit + Date of
Residence Established ✚G0318 ✚99417 112 Minutes Visit + 7 days after
Patient

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 Knowledge Check 1

Initial Day –POS-Inpatient

Payer: Cigna
78 y.o.  Male with a history significant for HTN, HL, DM, nephrolithiasis, and remote tobacco use. He
presented to Inspira Elmer yesterday with chest heaviness that began on 12/18. He was found to have
inferior STEMI, HS troponin 2680 -> 3830. He was loaded with brilinta and admitted. Placed on IV
antibiotics.  I have spent total 105 minutes for this patient today in discussing treatment options and
clarified all the question.

Answer: 99223, +99418*2

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 Knowledge Check 2
PROGRESS NOTE
Payer – Medicare
Place of Service: Observation
SUBJECTIVE: Doing decently well.  Still has left hip pain.  Pain medication seems to be helping.  Does have
some nausea.  Denies any fevers or chills. Denies any chest pain or shortness of breath.  Understands that
he might have surgery by tomorrow.
ASSESSMENT AND PLAN: Fracture of neck of left femur, Diabetes mellitus type 2 , Chronic obstructive
pulmonary disease not in exacerbation, Hypertension, Gastroesophageal reflux disease
Seemingly looks pretty good today.  Does have left hip pain.  Given Codeine IV for pain. Does have some
nausea was slightly low BP.  Give a fluid bolus of 500 cc normal saline.  Also Zofran for nausea.  Rechecked
and reviewed labs.  Hopefully can have surgery by tomorrow if it is necessary.  Orthopedics consultation
initiated, discussed with Dr. Callie.
I have spent total 93 minutes for this patient today in discussing treatment options and clarified all the
questions.

Answer: 99223, +G0316

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 Knowledge Check 3
Mother presents with a 4 y/o daughter for ear problem. Mother denies fever. Provider examines
patient, upon physical examination of Ear, tympanic membrane o revealed middle ear irritation.
Provider advised Tylenol and follow up with PCP if condition worsens.

Answer:

 NUMBER AND COMPLEXITY OF PROBLEMS ADDRESSED:

 Low-1 acute uncomplicated illness

 AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED AND ANALYZED:

 Limited (independent historian – mom)

 RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT:

 Low risk of morbidity from additional diagnostic testing or treatment documented - OTC

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 Knowledge Check 4
“Otitis media, treatment previously started and condition improving”
The above mentioned condition qualifies to which element of problem addressed?
A. Self-limited or minor problem
B. Stable, chronic illness
C. Stable, acute illness
D. Undiagnosed new problem with uncertain prognosis

Answer: Stable, acute illness

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 Knowledge Check 5
“Decision regarding hospital level care must be appropriate based on the patient’s condition”
The above statement is True or False-

Answer: True

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 Knowledge Check 6

“Parenteral controlled substances” - Is a newly added element under which of the following category
for the year 2023-
A. Low level at problem addressed
B. Moderate level at risk
C. High level at problem addressed
D. High level at risk

Answer: High level at risk

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 Knowledge Check 10
CPT description for the Prolonged services add on code 99418-

Prolonged inpatient or observation evaluation and management service(s) time with or without direct
patient contact beyond the required time of the primary service when the primary service level has been
selected using total time, each ___________ of total time

A. each 60 minutes of total time

B. each 35 minutes of total time
C. each 15 minutes of total time
D. each 30 minutes of total time

Answer: each 15 minutes of total time

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QUERIES???

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Thank you!
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