2023 E/M Guidelines Changes for Hospital Inpatient and Observation Care Services

The new year has started and what did 2023 bring us? Well for the new codes sets for 2023 it provided healthcare professionals with 225 added CPT codes, 75 deleted and 93 revised codes. That is 393 total changes with 10,969 total codes in 2023 code set.  Doesn’t that sound great!! The American Medical Association( AMA) published may changes that are impacting CPT E/M codes and guidelines that took effect January 1,2023. 
 
The revision we are going to look at in this section is Inpatient and observation care services. 

Medical decision-making (MDM) or provider total time spent performing the E/M services on the sate of the visit that is used to drive the E/M code selection. The only codes that must continue to use MDM is ED visits.
Now let’s review the  new/revised codes:

Initial Hospital Inpatient or Observation Care
99221- Initial 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,
 40 minutes must be met or exceeded.

99222- Initial 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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.

99223- Initial 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.

Subsequent Hospital Inpatient or Observation Care

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.


99232- 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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.

99233- 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.

Hospital Inpatient or Observation Discharge Services
99238- Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter

99239- Hospital inpatient or observation discharge day management; more than 30 minutes on the date of the encounter.

This includes, appropriate the final examination, discussion of the hospital stays, instructors for care to all relevant caregivers, and the preparation of the discharge records along with the prescriptions, and referral forms for the patient.

Hospital Inpatient or Observation Care (including Admission and Discharge Services)
99234-Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, 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, 45 minutes must be met or exceeded.

99235-Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.

99236-Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded

How do you select these codes based on time or MDM?
Time alone can be used to select the appropriate E/M codes for the service that was provided . The documentation must clearly describe what was done and time documented and reported must be appropriate given to the services that was described in the documentation. The tasks that are typically performed by clinical staff that are performed by a physician or AAP cannot be counted.
AMA states that total face-to-face and non-face-to-face time personally spent by the physician or APP in qualifying activities on the day of the visit cab be used to determine the code level. The encounter must be performed face-to-face, and you can only count unique time. That means no sharing of time between the provider and the APP at any time.  Staff time does not count.

Wonder what is included for time-based coding?
With the physician/APP time, it includes the follow activities when performed:
•	Preparing to see the patient (e.g., review of test results)
•	Obtaining and/or reviewing separately obtained history
•	Performing a medically appropriate examination and/or evaluation
•	Counseling and educating the patient/family/caregiver
•	Ordering medications, tests, or procedures
•	Referring and communicating with other health care professionals ( when not separately reported)
•	Documenting clinical information in the electronic or other health record
•	Independently interpreting results and communicating results to the patient/family/caregiver
•	Care coordination
Unfortunately, you can not count the time spent performing of other services that are reported, travel or teaching that is general and not limited to discussion that is required for the management of a specific patient. 

What if you would like to use MDM instead of time?
Medical Decision Making consists of 3 elements:
1.	Number and complexity of problems addressed at the encounter
2.	Amount and/or complexity of data to be reviewed and analyzed
3.	Risk of complication and/or morbidity or mortality of patient management
There are four levels of MDM, and they are:
1.	Straightforward
2.	Low
3.	Moderate
4.	High

Now remember two or three MDM elements must be meet or exceed a level to reach the overall MDM level. 

Example: 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.


Prolonged Psychotherapy Services
Psychotherapy was not spared from the 2023 E/M revisions. Prolonged services codes 99354, 99355, 99356, 99357 have been deleted from the E/M section. The guidelines for Psychotherapy and E/M reported together now read:

Medical symptoms and disorders inform treatment choices of psychotherapeutic interventions, and data from therapeutic communication are used to evaluate the presence, type, and severity of medical symptoms and disorders. For the purposes of reporting, the medical and psychotherapeutic components of the service may be separately identified as follows: 

1. The type and level of E/M service is selected first based up on the key components of history, examination, and medical decision making. 

2. Time spent on the associated with activities used to meet criteria for of the E/M service is not included in the time used for reporting the psychotherapy service (i.e., time spent on history, examination and medical decision making when used for the E/M service is not psychotherapy time) . Time may not be used as the basis of E/M code selection and Prolonged Services may not be reported when psychotherapy with E/M (90833, 90836, 90838) are reported. 

3. A separate diagnosis is not required for the reporting of E/M and psychotherapy on the same date of service.◄

Pay close attention to the guidelines that are amended  in the 2023 CPT code book. These guidelines will help you select the appropriate code correctly.To see more of AMA changes for E/M, click this link https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf