Get the Latest Changes to E/M Coding Guidelines
November 15, 2022
Each year, the American Medical Association (AMA) issues new guidance for E/M coding. The good news for urgent care is that this year, many of the changes refer primarily to health systems and hospitals. Nonetheless, it’s important to be sure your staff is familiar with what is new. In this blog we’ll also provide some tips to block phishing scams as well as explore some initiatives by Health and Human Services to improve rural healthcare access and be sure the underserved populations have options to be well.
The changes that the American Medical Association (AMA) will make to their E/M Guidelines for 2023 have minimal impact to the office/urgent care setting. The purpose of these changes is to roll out the new guidelines implemented in 2021 for all categories of E/M.
With these published changes, the 1995/1997 guidelines will be completely retired. Experity may have the opportunity to support other categories of codes with their coding engine.
Two new options will be added to the Low category of Problem Addressed.
1 stable, acute illness
“Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to the condition.”
1 acute uncomplicated illness or injury requiring hospital inpatient or observation level of care
“Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.”
This section option is for the hospital setting only.
In addition to these new definitions, condition examples will be removed from all definitions for Problem Addressed.
History and/or Examination
“E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service.”
The words “when performed” will be added to the descriptions for E/M codes 99202-99215. This indicates if a history or examination is not necessary it does not need to be documented. It may be necessary to support Problem Addressed or Data Reviewed, however.
When leveling based on time, the total time needs to appear in the actual medical record. CMS has suggested that the record state the level was selected based on time.
Independent Historian
The AMA clarified that a translator should not be counted as an independent historian. As the translator does not have a history or is not involved in management of the patient, use of a translator does not count in the Data Reviewed section. However, the need for a translator could be a Social Determinant of Health (SDoH) in some instances. This could be a Moderate level of Risk of Management.
The AMA has the following definition for shared visits.
“A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) both provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient and/or counseling, educating, communicating results to the patient/family/caregiver on the date of the encounter is summed to define total time.
Only distinct time should be summed for shared or split visits (i.e., when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).”
This definition does not align with the guidelines from the Centers for Medicare & Medicaid Services (CMS) on shared/split visits. Medicare policy is that shared visits are for the hospital setting only.
Consultations
The lowest level, 99241, will be deleted in 2023.
| Code | MDM | Time (Met or Exceeded) |
| 99242 | Straightforward | 20 minutes |
| 99243 | Low | 30 minutes |
| 99244 | Moderate | 40 minutes |
| 99245 | High | 55 minutes |
Consultations are rarely performed in the urgent care setting. Most payers follow Medicare guidelines and do not reimburse for consultations.
Home Visits
The categories for domiciliary, rest home, and custodial care will be deleted in 2023. Included are codes 99324-99328, 99334-99337, 99339, and 99340. Services in these settings will be reported with the home visit codes. The Place of Service (POS) will identify the type of facility.
Code 99343 will be deleted in 2023
| Code | Patient Type | MDM | Time (Met or Exceeded) |
| 99341 | New | Straightforward | 15 minutes |
| 99342 | New | Low | 30 minutes |
| 99344 | New | Moderate | 60 minutes |
| 99345 | New | High | 75 minutes |
| 99347 | Established | Straightforward | 20 minutes |
| 99348 | Established | Low | 30 minutes |
| 99349 | Established | Moderate | 40 minutes |
| 99350 | Established | High | 60 minutes |
Nursing Facility Services
These codes are used by the admitting physician or specialists. HCPCS modifier “AI” is required on the admitting physician claim to identify their role in the care of the patient.
Code 99318 will be deleted in 2023.
| Code | Visit Type | MDM | Time (Met or Exceeded) |
| 99304 | Initial | Straightforward or Low | 25 minutes |
| 99305 | Initial | Moderate | 35 minutes |
| 99306 | Initial | High | 45 minutes |
| 99307 | Subsequent | Straightforward | 10 minutes |
| 99308 | Subsequent | Low | 15 minutes |
| 99309 | Subsequent | Moderate | 30 minutes |
| 99310 | Subsequent | High | 45 minutes |
| 99315 | Discharge | N/A | 30 minutes or less |
| 99316 | Discharge | N/A | More than 30 minutes |
These codes are also used for skilled nursing facilities. The POS is used to report the type of facility where the service is performed. Nursing facility is POS 32; skilled nursing facility is POS 31.
This definition is unique to nursing facilities:
“Multiple morbidities requiring intensive management: A set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations. The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital.”
Existing face-to-face prolonged services codes 99354-99357 will be deleted for 2023.
Two options remain for reporting prolonged services in the office or home setting:
A new prolonged services code will be added for the inpatient, observation, or nursing facility setting. The AMA is using placeholder 993X0 for now.
Other prolonged services codes:
Hint: Quiz staff on phishing ploys
Even the most tech-savvy folks get duped by email phishing and malspam. It’s critical that you take the time to educate your staff members on how to react to even the simplest virus or hoax — or you risk leaking your patients’ electronic protected health information (ePHI).
Use these 10 tips for protecting ePHI and your organization against an accidental malware attack
Keep these tips handy to serve as a reminder the next time you receive an unsolicited email with an attachment.
CMS offers several rural healthcare fixes in MPFS proposed rule.
The pandemic revealed that access to safe and affordable healthcare isn’t always guaranteed. The feds continue to try to rectify these equity issues with recent funding and policy making. Read on for the scoop on three items to know.
In the Medicare Physician Fee Schedule (MPFS) proposed rule published in the Federal Register on July 29, the Centers for Medicare & Medicaid Services (CMS) offers up a few proposals to assist providers helping beneficiaries at Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Reminder: RHCs are Medicare-certified and offer primary care specifically in rural areas with limited healthcare options. FQHCs operate in both rural and urban locations that have provider shortages and assist patients with both primary and dental care. Both types of facilities must meet certain Medicare standards and comply with Conditions of Coverage and Certification.
First, CMS wants to make chronic pain management a priority at RHCs and FQHCs. “We are proposing to include chronic pain management services in the general care management HCPCS code G0511 [Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month] when these services are provided by RHCs and FQHCs,” notes the proposed rule. The expansion of G0511 would have little impact on Medicare spending “since the requirements for the new chronic pain management and behavioral health integration services are similar to the requirements for the general care management services furnished by RHCs and FQHCs” already, CMS reasons.
Two other proposals focus on telehealth provisions outlined in the Consolidated Appropriations Act, 2022 (CAA, 2022) and deal with the post-COVID-19 public health emergency (PHE) transition. CMS wants to extend telehealth flexibilities for RHCs and FQHCs for 151 days after the PHE ends.
The Department of Health and Human Services (HHS) intends to improve community and public health resources for patients in underserved areas by investing more than $266 million in providers and programs.
“Patients depend on community and public health workers for care and medical information,” expounds HHS Secretary Xavier Becerra in an HHS release. “These investments will equip community and public health workers with the skill sets needed to provide effective community outreach, increase access to care, and assist individuals with critical prevention and treatment services.”
Details: The HHS Health Resources and Services Administration (HRSA) will disperse upward of $225 million to 83 grantees via its Community Health Worker Training Program, training and supporting 13,000 workers. The health members include “promotores de salud, community health advisors, outreach workers, patient navigators and peer counselors,” who all strive to connect people and build trust in communities, HHS says.
Another $47 million is earmarked for the Public Health Scholarship Program and will be distributed to 29 grantees by HRSA, incentivizing individuals to pursue public health careers.
If you want to offer the feds your two cents on reducing regulatory burdens, CMS is soliciting input with a new Request for Information (RFI) titled “Make Your Voice Heard: Promoting Efficiency and Equity Within CMS Programs.”
CMS “is committed to engaging with partners, communities, and individuals across the health system to understand their experiences with CMS payment policies and quality programs, particularly how existing and proposed CMS payment policies and quality programs impact the experience of healthcare,” the agency says on the RFI webpage.
“Through this RFI, CMS is seeking public input on accessing healthcare and related challenges, understanding provider experiences, advancing health equity, and assessing the impact of waivers and flexibilities provided in response to the COVID-19 public health emergency (PHE),” the agency explains. “CMS will use the comments received … to identify potential opportunities for improvement and increased efficiencies across CMS policies, programs, and practices,” it adds.
“This RFI aims to gather feedback and perspectives related to … reducing burden, and creating efficiencies across the healthcare system,” CMS says in a release.
We were recently informed that a client received an email from a scammer who represented themselves as Experity. This email contained instructions to change the bank account information for making payments to us which the client followed, giving the scammer access to their account information.
The situation has been resolved, but in today’s security environment it’s an important reminder that we all remain vigilant in protecting ourselves from phishing attempts and other forms of cyber-attacks.
IMPORTANT: Experity personnel will never ask you via email or text to change bank information for remitting payments to us. If you receive a request of this nature, please contact us immediately at invoices@experityhealth.com.
REMINDER: The most secure way to make a payment to us is through our VersaPay payment portal. If you haven’t yet created a VersaPay login, please contact us at invoices@experityhealth.com to set one up.
CMS is currently considering 2023 Medicare payment rates and they need to hear from Urgent Care physicians and APPs ASAP on the current reimbursement rate for the combined COVID-19/Influenza A/Influenza B point-of-care diagnostic test (CPT 87428). For the second year in a row, the Clinical Diagnostic Laboratory Tests (CDLT) Advisory Panel’s recommendations support a significant increase in payments ($63.59).
The current payment rate for this multiplex test ($30.94) is almost 12.5% lower than the payment rate for the standalone COVID-19 test ($35.33). Last year, CMS did not follow the Advisory Panel’s recommendations for an increase, and we want to ensure that they hear from clinicians this year before making a final decision. UCA is writing a letter to CMS on behalf of the industry, and we would request that you send emails to your Senators asking them to pressure CMS to follow the CDLT Panel recommendations for an increase in payments.
Click here to send a letter to your senators today! They could make a final decision regarding this matter as early as this week. If you have any questions, please email Kyoungblood@ucaoa.org
Interested in more urgent care tips, best practices, and industry updates? Check out our September and October installments.
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