Following a major update to office and outpatient evaluation and management (E/M) guidelines and reporting in 2021, the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) made similar changes to other E/M categories in 2023. Understanding these changes is important because E/M services are common for many healthcare organizations and therefore play a key role in financial health and compliance programs.
On Jan. 1, 2021, the AMA implemented revised guidelines and code descriptors for office and other outpatient services E/M codes 99202-99215. The coding guidelines were overhauled to change the code selection requirements to be based on medical decision making (MDM) or total time of the E/M service. The revisions eliminated the requirement to meet a certain level of history and exam, instead requiring a medically appropriate history and/or physical exam.
The goals for these changes were to reduce administrative burden and better align coding with how patient care is delivered today. Patient care should be driven by the need to treat patients, not the need to satisfy a coding requirement.
The AMA revised the 2023 E/M guidelines to be consistent with the changes implemented in 2021 and to support all other E/M categories, including hospital or observation services, inpatient and outpatient consultations, emergency department services, nursing facility services, and home or residence services.
Observation and inpatient services: CPT ® 2023 deleted observation services codes 99217-99220 and 99224-99226. To allow reporting of observation services, CPT ® revised the hospital services category to represent either hospital or observation services (99221-99239). The examples below of 2022 code 99224 (deleted for 2023) and 2023 code 99231 show how observation care is now represented by the same code as inpatient care. These codes also illustrate how E/M changed the requirements and wording related to history, exam, MDM, and time.
Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
Problem focused interval history;
Problem focused examination;
Medical decision making that is straightforward or of low complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the patient is stable, recovering, or improving. Typically, 15 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99231 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 straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
Consultations: CPT ® deleted consultation codes 99241 (office/outpatient) and 99251 (inpatient) in 2023 because both represented straightforward MDM, which is the same level of MDM assigned to office/outpatient code 99242 and inpatient code 99252. Under the new coding structure where code choice can be based on MDM, it does not make sense to have the same MDM level assigned to two different codes that apply to the same type of service. These deletions are in line with the 2021 deletion of 99201 for office and other outpatient services. Code 99201 required straightforward MDM, the same as 99202.
Nursing facility services: CPT ® 2023 deleted the annual nursing facility assessment code 99318, instructing you now to report that service using subsequent nursing facility services codes 99307-99310.
Home or residence services: CPT ® deleted the domiciliary, rest home (e.g., boarding home), or custodial care services codes (99324-99337), and CPT ® revised the home services codes to include home or residence services (99341-99350). In place of deleted home, domiciliary, or rest home care plan oversight codes 99339 and 99340, CPT ® points coders to chronic care management codes 99491 and +99437 or principal care management codes 99424 and +99425, although those codes are not specific to home or residence services.
Hospital Observation Services (initial, subsequent and discharge codes)
Deleted; report using revised Hospital Inpatient and Observation Care Services
Office or Other Outpatient Consultations