In 2021, the Current Procedural Terminology (CPT*) Editorial Panel revised the office/outpatient evaluation and management (E/M) codes (99202–99205, 99211–99215). For CPT 2023, the panel has revised additional families of E/M codes to be consistent with the changes to the office/outpatient E/M codes. This column focuses on the changes to the hospital inpatient and hospital observation E/M codes that surgeons routinely use.
Will there continue to be separate E/M codes for inpatient and observation care in 2023?
No, for 2023, the codes for reporting observation care services (99217–99220) will be deleted and observation care services will be merged into the codes previously used to report only inpatient care services (99221–99233, 99238–99239). See Table 1 for the revised 2023 code descriptors. Although the same code will be used to report either inpatient or observation care services, you will still need to know the facility status of the patient to accurately report the place of service code as either hospital inpatient (21) or hospital outpatient (22).
Will there continue to be separate codes for initial and subsequent hospital visits?
Yes, codes 99221–99223 will continue to be reported for new patients and codes 99231–99233 will continue to be reported for established patients.
In addition to merging inpatient and observation care services into single codes, how else has this family of codes changed?
Similar to the changes made to the office/outpatient E/M codes, only a “medically appropriate” history and/or examination will be required for reporting inpatient/observation care services. The extent of history and physical examination is not an element in selecting the level of these E/M codes. In addition, references to a “focused, detailed, or comprehensive” history and/or examination have been removed from the code descriptors.
How do I select the correct code?
Code selection will be based on either the level of medical decision-making (MDM) as defined for each service or the total time on the date of the encounter. These elements will be used for selecting all hospital E/M visit codes with the exception of emergency department visit codes (which only use MDM) and critical care services codes (which only use time).
How is MDM used to select the level of code?
For codes 99221–99223 and 99231–99233, the level (straightforward, low, moderate, high) of MDM selected is based on two of the three elements of MDM: (1) number and complexity of problems addressed at the encounter, (2) amount and/or complexity of data to be reviewed and analyzed, and/or (3) risk of complications and/or morbidity or mortality of patient management. These are exactly the same elements used to select a level of office/outpatient E/M services code.
How do I use total time to select a level of code?
When time is used for reporting inpatient/observation care E/M services codes, the time defined in the code descriptors is used for selecting the appropriate level of services. The time includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified healthcare professional (QHP) on the date of the encounter. It includes time regardless of the location of the physician/QHP (for example, whether on or off the inpatient/observation unit). It does not include any time spent in the performance of other separately reported procedures or service(s). For coding purposes, time for these services is the total time on the date of the encounter.
How is time reported if both the physician and QHP provide face-to-face and non-face-to-face services on the day of encounter?
A visit in which a physician and QHP both provide services related to the visit is defined as a split or shared visit. When time is being used to select the appropriate level of services for which time-based reporting of split/shared visits is allowed, the time personally spent by the physician and QHP 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. However, remember that only distinct time should be summed for split/shared visits (for example, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
I have heard there are new restrictions for reporting split/shared visits—is this true?
For Medicare patients in 2022, the Centers for Medicare & Medicaid Services finalized that the treating provider who performs the “substantive portion” of the visit will bill the service. For more information on 2022 reporting, see the April 2022 issue of the Bulletin. For 2023, based on negative comments about the plan that CMS created for 2022, along with changes to the code descriptors, the reporting requirements for a split/shared visit are under review. Look for an update after the final rule for the 2023 physician fee schedule is released in November.
What resources does the ACS offer to improve my coding skills?
The ACS collaborates with KarenZupko & Associates (KZA) to offer coding courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills. You also will be provided online access to the KZA alumni site, where you will find additional resources and frequently asked questions about correct coding. Additional information about the courses and registration can be accessed at karenzupko.com/general-surgery.
