New rules for reporting evaluation and management (E/M) services in most places of service took effect January 1, 2023. The coding and documentation revisions, adopted by the American Medical Association’s CPT Editorial Panel and approved by the Centers for Medicare and Medicaid Services (CMS), substantially simplify code selection and documentation.
Effective January 1st, E/M services have their own thresholds of the three medical decision-making elements. When reviewing an encounter, if what was medically necessary, performed, and documented meets the threshold of two of the three elements for that level, that E/M level may be selected.
Although you should still perform a medically appropriate history and/or physical exam, it/they do not determine the level of service.
Coding Based on MDM
The four levels of MDM remain the same: straightforward, low, medium, and high. To qualify for a level of MDM, two of the three elements for that level of decision-making must be met.
The three core elements have remained essentially the same and they are:
- Number and complexity of problem(s)
- Amount and/or complexity of data to be reviewed and analyzed.
- Risk of complications and/or morbidity or mortality of patient management decisions made at the visit.
Coding Based on Time
The biggest change in E/M coding and documentation is that code selection for patient visits can now be based entirely on time spent on the day of the encounter – even if counseling and coordination of care do not dominate the encounter. Clinical staff time does not count.
To learn more about how Blue & Co. can help your organization with opportunities surrounding the 2023 Physician Fee Schedule Final Rule, reach out to your local Blue & Co. advisor or contact a member of our Revenue Cycle team below.
Beverly Strube, CPC, COC, CPC-I, CPMA, CEMC, COBGC, Senior Physician Coding Consultant
Scott Treida, Director
Maddie Gookins, Director