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2023 MDM and E/M Code Updates

Swiftaudit now supports all current AMA updates to Medical Decision Making and E/M code calculations. We’ll be posting a series of educational discussion pieces over the next few weeks to dig deeper into these changes, so stay tuned! In the meantime, here is a brief summary of revisions.

2023 summary of revisions to the E/M code descriptors and guidelines

Inpatient and observation care services

  • Deletion of observation CPT codes (99217-99220, 99224-99226) and merged into the existing hospital care CPT codes (99221, 9922299223, 99221-99233, 99238-99239).
  • Editorial revisions to the code descriptors to reflect 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) (99234-99236).
  • Revision of guidelines.

Consultations

  • Retention of the consultation codes, with minor, editorial revision to the code descriptors.
  • Deletion of confusing guidelines, 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.

Emergency department services

  • Maintained the existing principle that time cannot be used as a key criterion for code level selection.
  • Editorial 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.
  • Existing CPT code numbers maintained (analogous to office visit revisions).
  • Articulated current practice that was not explicit in the CPT code set.
    • May be used by physicians and QHPs other than just the ED staff.
  • Critical care may be reported in addition to ED service for clinical change.

Nursing facility services

  • Editorial revisions to the code descriptors to reflect the new standard E/M code structure.
  • Revision to nursing facility guidelines with 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). This existing service will be reported through the subsequent nursing facility care services (99307-99310) or Medicare G codes.
  • Not all “initial care” codes are the mandated comprehensive “admission assessment” and may be used by consultants.
  • Use subsequent visit when the principal physician’s team member performs care before the required comprehensive assessment.

Home and residence services

  • Editorial revisions to the code descriptors to reflect the new standard E/M code structure.
  • The domiciliary or rest home CPT codes (99334-99340) were deleted and merged with the existing home visit CPT codes (99341-99350).
  • Elimination of duplicate MDM Level New Patient code (99343).

Prolonged services

  • Deletion of direct patient contact prolonged service codes (99354-99357). These services will now 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).
    • 99417 is also used for Home or Residence prolonged services.
  • Creation of a new code (993X0) to be analogous to the office visit prolonged services code (99417). This new code is to be used with the inpatient or observation or nursing facility services.
  • Retention of 99358, 99359 for use on dates other than the date of any reported ‘total time on the date of the encounter” service.

More Information:

Review and download the E/M code descriptors and guidelines for 2023.

FAQs

2023 Observation and Consultation EM

By Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CPCO, CENTC, CMCS


A client asked me how she should bill consultations for patients that are in Observation status, for payers who still recognize consultation codes and for payers who no longer acknowledge consultation codes. She is confused about the difference between an “other outpatient” status and Observation status.

As 2023 starts, here are my thoughts.

The question is Location, Location, Location.

According to AMA CPT 2023 Office or Other Outpatient Consultations, 99242 – 99245,

“The following codes may be used to report consultations that are provided in the office or other outpatient site, including the home or residence, or emergency department.”

According to AMA CPT 2023 Inpatient or Observation Consultations, 99252 – 99255,

“Codes 99252, 99253, 99254, 99255 are used to report physician or other qualified health care professional consultations provided to hospital inpatients, observation level patients, residents of nursing facilities, or patients in partial hospital setting, and when the patient has not received any face-to-face professional services from the physician or other qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the stay.”

For payers who process consult codes, use the EM codes based on status/location.

For payers who do not process consult codes, here is my advice for patients in hospital observation level status.

2023 Revisions to 2021 E/M Guidelines says that patients that are not admitted and discharged to and from observation on the same day (99234-99236) and a minimum of 8 hours of observation is expended, that admission codes 99221-99223 should be used. For follow up care, subsequent hospital visits 99231-99233 should be used; and when the patient is discharged from Observation, 99238-99239 should be used.

What about the POS?

Now the question is what should the Place of Service (POS) be given that the patient is in Observation status?

We have always been taught that 99221-99233 and 99238-99239 are only billed as inpatient POS. But observation status patients are in outpatient. None of the guidance has stated what POS should be used. However those knowledgeable have indicated that they feel that we have been told to bill observation status patients as OUTPATIENT POS even when using traditionally inpatient codes 99221-99233 and 99238-99239. Billing consultations for payers who do not recognize the consultation CPT codes should be coded and billed as follows:

  1. If the patient is a Medicare Part B patient, and a consultation is performed on a patient in Observation level status, I would code 99221-99223 with POS outpatient, 22. The admitting doctor, who admitted the patient to Observation level status should have used the AI with 99221-99223 to indicate that they are the admitting doctor of record.
  2. If the patient is NOT Medicare Part B you need to determine if the payer has instructed the providers to bill consultations using initial hospital visits when a consultation is performed inpatient. If they have provided this instruction, hopefully in writing, follow the above paragraph’s instructions for Medicare Part B patients in #1 above.
  3. If the patient is not Medicare Part B and the payer has not indicated that they will process consultations for inpatients using initial hospital visits, rather they want providers to just bill subsequent hospital visits, then bill a subsequent hospital visit, 99231-99233 but since the patient is in Observation, the POS will be outpatient, 22.

Because we have not received implicit instructions to bill consultation to patients in hospital observation level status using POS of Outpatient, POS 22, we will have to see how payers are going to process the codes 99252 – 99255 with POS 22 over the first couple weeks.

So, keep an eye on your remittances that come in for all of your 2023 Observation billing that you do in January and get a pulse on how the third-party payers are processing your claims. If they are not accepting POS 22, outpatient, inquire to the third-party payers how they want observation status patients billed and get it in writing.

Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CPCO, CENTC, CMCS


Graphic Acknowledgement: Designed by stories / Freepik

2023 ICD-10-CM Guidelines By Chapter

The official 2023 ICD-10-CM Guidelines are now available and active! This updated code set is to be used for discharges and patient encounters occurring from October 1, 2022 through September 30, 2023. It’s time to get familiar with what’s new and what has changed.

To help provide a quick reference, we have split the original 118 page document into separate Chapters, each approximately 2-5 pages long and with a focus on specific code groups. By referencing our Chapter list you can more efficiently focus on the specialty you are coding, auditing or teaching.

Be sure to review Section 1.B. General Coding Guidelines for the latest ICD-10-CM general coding guidance.

See what has changed for ICD-10-CM in 2023 in the Tabular Addenda (42 pages).

FY 2023 ICD-10-CM Guidelines (as of July 2022)

Section 1.A: Code Conventions

Section 1.B: General Coding Guidelines

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

Chapter 2: Neoplasms (C00-D49)

Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) — Reserved for future guideline expansion

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

Chapter 6: Diseases of the Nervous System (G00-G99)

Chapter 7: Diseases of the Eye and Adnexa (H00-H59)

Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) — Reserved for future guideline expansion

Chapter 9: Diseases of the Circulatory System (I00-I99)

Chapter 10: Diseases of the Respiratory System (J00-J99), U07.0

Chapter 11: Diseases of the Digestive System (K00-K95) — Reserved for future guideline expansion

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

Chapter 14: Diseases of Genitourinary System (N00-N99)

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)

Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

Chapter 20: External Causes of Morbidity (V00-Y99)

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Chapter 22: Codes for Special Purposes (U00-U85)

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2023 CMS Proposed ICD-10-CM changes

It may be hard to believe but ICD-10 updates for October 2022 are already just around the corner. Sheri Poe Bernard recently posted a link to the CMS Proposed ICD-10 updates, highlighting some of the more interesting changes coming up.

Here is a quick summary of the new ICD-10-CM codes by chapter.

These new ICD-10-CM codes recognize injuries and conditions caused by several elements we see in today’s world. For example, as a result of our aging population there are over 60 new codes related to dementia. CMS also added the Z91.A series, given that caregivers impact their patient’s health.

The current offering of motorized transportation options has also initiated a variety of interesting new codes. Case in point, there are now 237 new codes related to “Electric (assisted) bicycle.” For example: V20.01XA: Electric (assisted) bicycle driver injured in collision with pedestrian or animal in nontraffic accident, initial encounter.

Similarly, there are also 237 new codes relate to motorcycle injuries. For example: V20.09XA: Other motorcycle driver injured in collision with pedestrian or animal in nontraffic accident, initial encounter.

As we move towards a more energy conscious world, there are best practices to stay safe and there will be “a code for that!” when injuries occur.

For a more detailed look at the proposed changes: FY 2023 IPPS Proposed Rule Home Page

Swiftaudit New Products Release

We’re excited to announce the upcoming launch of our new products and features for Swiftaudit.

For the past year, the SpringSoft Medical team has worked to add several new features to our core Swiftaudit Essentials platform. We listened to you, designing features to make your jobs easier.

On March 1, 2022 our new Swiftaudit product series will be online and available:
CodeBook which provides access to our Coding Tools on your phone, tablet or PC.
Essentials is our core Swiftaudit platform supporting pro-fee reviews, and includes Codebook.
Standard starts with Essentials and adds the ability to upload billing data into an auditor work queue.
Standard+RA supports reviews for pro-fee and risk adjustment.

In addition to these new products and features, we are upgrading our payment platform with improved invoices and payment receipts.

To facilitate the launch of our new product line, there will be a brief interruption of service from 8:00AM to 9:00AM on Tuesday, March 1st, 2022 (EST).

Swiftaudit will be unavailable during this time.