2023 CPT E/M Descriptors and Guidelines Updates March 29, 2023
In cooperation with the American Medical Association (AMA), a set of new Current Procedural Terminology (CPT) coding guidelines for 2023 was published. These changes simplified medical coding for procedures related to evaluation and management (E/M), which took effect last January 1, 2023.
CPT® Evaluation and Management (E/M)Code and Guideline Changes
For a complete overview of the American Medical Association (AMA) changes, please click (PDF) file.
Why are CPT codes so important?
Providers and payers interact through CPT® — the language of medical billing and reimbursement.
The Current Procedural Terminology is an essential and expansive code set maintained by the American Medical Association (AMA). It is one of the essential code sets for medical coders to understand. Medical providers use the CPT coding guidelines to describe tests, surgeries, evaluations, and other procedures they perform on patients. There are thousands upon thousands of medical procedure codes in this code set, which are an integral part of the billing process. Healthcare providers use CPT codes to indicate what procedures they wish to be reimbursed for.
Therefore, CPT codes are used in conjunction with ICD codes to present a complete picture of the medical process to payers. “The patient had these symptoms (represented by the ICD code), and we carried out these procedures (represented by the CPT code).
Learn more about the meaning of CPT codes.
2023 CPT E/M Descriptors and Guidelines Updates
The coding guidelines CPT 2023 changes are designed to align with E/M coding standards across care settings and services. Below are the 2023 CPT updates and some guidelines based on the care setting or service:
Inpatient CPT Codes and Observation Care Services
- Deletion of observation CPT codes (99217 through 99220 and 99224 through 99226) and merged them into the existing hospital care CPT codes (99221 through 99223, 99221 through 99233, and 99238 through 99239)
- Revision of the code descriptors to account for the structure of total time on the date of the encounter or level of medical decision-making when selecting code level
- Retention of revised observation or inpatient care services, including admission and discharge services (CPT codes 99234 through 99236)
*In the guidelines for this section, CPT® emphasizes that when advanced nurse practitioners and physician assistants work with physicians, they are considered to be working in the same specialty as the physician. AMA guidelines have also been revised regarding the admission of patients from other hospitals. Although Medicare or other players may not adhere to this guidance, this is what the AMA suggests.
Suppose a patient is admitted to the hospital as an inpatient or for observation services during an encounter at another care site (e.g. emergency department, office, or nursing facility). In that case, the services provided at the initial location may be reported separately. Modifier 25 can be applied to other Evaluation and Management services to indicate that a discrete, noteworthy service was provided by the same physician or other qualified healthcare professionals on the same date.
The American Medical Association (AMA) advises that a patient’s status change from inpatient or observation to inpatient or observation does not constitute a new stay and should not be billed for an additional initial service.
Consultations
- Retention of the consultation codes, with some editorial revision to the code descriptors
- Deletion of certain guidelines deemed confusing by the AMA, including the definition of “transfer of care.”
- Deletion of lowest-level office (99241) and inpatient (99251) consultation codes to align with four levels of MDM
*Obtaining a consultation requires a request from another healthcare professional or appropriate source and a written report. Both of these should be documented in the consultation note. CPT 2023 removed the concept of transfer of care as a lens through which to evaluate consultations.
These codes are not recognized by Medicare and will not change its policies.
Emergency Department Services
- Retention of the existing principle that time cannot be used as a key criterion for code level selection
- Revisions to the code descriptors to reflect the code structure approved in the office visit revisions
- Modified MDM levels to align with office visits and maintain unique MDM levels for each visit
- Retention of existing CPT code numbers
- Updates to current practice that was not explicit in the CPT code set, which may be used by physicians and other qualified healthcare professionals other than ED staff
- Allowance of critical care to be reported in addition to ED service for clinical change
*It is unnecessary to present a doctor or qualified healthcare provider when performing Code 99281.
Nursing Facility Services
- Revision to nursing facility guidelines with a new “problem addressed” definition of “multiple morbidities requiring intensive management” to be considered at the high level for initial nursing facility care.
- Deletion of code 99318 (annual nursing facility assessment), which will be reported through the subsequent nursing facility care services (CPT codes 99307 through 99310) or Medicare G codes
- Updated standard so not all “initial care” codes are the mandated comprehensive “admission assessment” and may be used by consultants.
- Allowance of the use of subsequent visits when the principal physician’s team member performs care before the required comprehensive assessment
*The American Medical Association (AMA) agrees with Medicare rules that a physician must provide the initial comprehensive visit in a skilled nursing facility. Further, the AMA states that initial nursing facility services can be conducted by a physician or other qualified healthcare professional, regardless of the length of stay, as long as it is done once per admission. For nursing facilities not classified as ‘skilled’ (distinguished by state law or regulation), a healthcare professional may report the initial comprehensive nursing facility visit if the state laws or regulations permit it.
Home and Residence Services
- Deletion of the domiciliary or rest home CPT codes (99334 through 99340), which have now been merged with the existing home visit CPT codes (99341 through 99350)
- Elimination of the duplicate MDM Level New Patient code (99343)
*The AMA recommends not including travel time in selecting a code based on time.
Prolonged Services
- Deletion of direct patient contact prolonged service codes (99354 through 99357), which will be reported through either the code created in 2021, office prolonged service code (99417), or the new inpatient or observation or nursing facility service code (993X0)
- Creation of a new code (993X0) to be analogous to the office visit prolonged services code (99417)
- Retention of 99358 and 99359 for use on dates other than the date of any reported ‘total time on the date of the encounter” service
*The CPT® is making editorial modifications for prolonged clinical staff codes to 99415 and 99416. It is important to note Medicare does not pay for these codes. Beginning in 2023, the existing prolonged care code 99417, which currently only applies to 99205 and 99215, will now be reported with outpatient consult codes 99245, home visit codes 99345 and 99350, and cognitive assessment code 99483.
Note: The AMA owns the copyright on all the CPT 2023 e/m coding guidelines presented here.
Impact of AMA 2023 E/M Changes
The AMA has released the 2023 Current Procedural Terminology (CPT®) code set, the nation’s foremost data-sharing terminology for medical procedures and services. Furthermore, the 2023 CPT code set includes modifications to the codes and guidelines for the majority of evaluation and management (E/M) services, offering relief from the burden of complexity.
Overall, the revisions to E/M codes for office visit services in 2021 are intended to simplify the coding and documentation process for other E/M services, allowing physicians and care teams to focus on providing high-quality care to patients without being burdened by time-consuming administrative tasks.
Tap Into Our Expertise
The AMA released these 2023 CPT E/M code updates effective January 1, 2023. Would you like more information right now? We will continue to update our website content here in 5 Star Billing to inform you of coding changes as they occur.
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