Ongoing E/M overhaul seeks consistency across care settings

Andis Robeznieks , Senior News Writer

The efforts of the AMA work group that helped institute coding and documentation reforms for office and outpatient evaluation-and-management (E/M) services continues, as those changes—that were rolled out in 2021—will now be integrated into E/M codes, which are reportable across all health care settings.

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These changes to the Current Procedural Terminology (CPT®) code set were among the highlights of the AMA Outpatient CDI Workshop and CPT and RBRVS 2023 Annual Symposium, which was held virtually this year.

“We continue to do the overhaul that’s been necessary for revamping E/M services,” said Mark Synovec, MD, who chairs the CPT Editorial Panel, which has been authorized by the AMA Board of Trustees to revise, update and modify CPT codes, descriptors, rules and guidelines.

These changes, along with revisions to other code sets within the E/M section of CPT, accounted for 77 total changes (PDF), as there was one new code added, 26 deleted and 50 revised, said Dr. Synovec, also president of the Topeka Pathology Group, and pathology section chair in the AMA Specialty and Service Society Section Council.

The E/M section of the set covers codes 99202 through 99499, and next year will cover E/M services delivered in these settings:

  • Office or other outpatient facilities.
  • Hospital inpatient and observation care.
  • Emergency department care.
  • Nursing facility.
  • Home or residence.
  • Prolonged service with or without direct patient contact on the date of an E/M service.

The reform effort was led by AMA members Barbara Levy, MD, a former chair of the AMA/Specialty Society RVS Update Committee (RUC) and a current member of the AMA CPT Editorial Panel, and Peter Hollmann, MD, a former chair of the CPT Editorial Panel and now vice chair of the RUC.

Both Drs. Levy and Hollman participated in the symposium and explained what motivated the changes for 2023.

“Part of the major goal of all the changes that have been made to the E/M families is to create simplification and we hope that we were successful,” said Dr. Hollman, a geriatrician and chief medical officer of the Brown Medicine faculty medical group.

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“The theme throughout all of this is that we tried to create consistency among all the E/M services to the extent possible, so that same principles apply for the office and outpatient services now apply for hospital inpatient and other type of facility services,” said Dr. Levy, a clinical professor of obstetrics and gynecology at the George Washington University School of Medicine & Health Sciences.

Related specifically to the inpatient and observation status codes, “Many times, we do not know whether the patient is in observation status or inpatient status or will become inpatient or observation-care status, and frankly, the services that we provide are identical,” she added. “The times are identical, and the work required for management is identical. So, it was the strong feeling of the workgroup that we should combine these services into a single family of services.”

While the code sets for the different settings have been merged, each still requires the same place of service code as before.

Key changes to the E/M code set for 2023 include:

  • Deletion of codes 99217–99220 hospital observation services.
  • Integrated into hospital inpatient services 99221–99239.
  • 99221–99223 and 99231–99233 restructured to model outpatient office codes.

The E/M code set covers 55 pages in the CPT 2023 Professional Edition, and the AMA also offers a 40-page supplement known as the CPT E/M Companion.

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Social determinants of health and MDM

In addition to answering questions about what to expect in 2023, during a Q&A session in the symposium, questions came up about the addition of a social determinants of health element in the 2023 code set for determining the level of medical decision-making (MDM).

The code set lists “diagnosis or treatment significantly limited by social determinants of health” as a moderate risk factor in a moderate level of MDM.

Dr. Levy explained that social determinants of health can affect a decision to admit a patient experiencing homelessness who has pneumonia or an infection that could be treated on an outpatient basis under different circumstances. It could also affect treatment options for diabetes if the person cannot afford medication.

But she added that a patient’s lack of housing or financial insecurity don’t automatically elevate the level of MDM. To do so, the social determinant must have an effect on the decision being made.

The AMA has additional resources on implementing the E/M outpatient and office-visit revisions, including step-by-step videos. Summaries of the revisions and explanations of how they will reduce administrative burdens are also available.