The Continued Evolution of E/M Services
To standardize the evaluation and management (“E/M”) code set across service settings, the Centers for Medicare and Medicaid Services (“CMS”) proposed to adopt the American Medical Association’s (“AMA”) documentation and coding revisions for inpatient, observation, emergency department, nursing facility, and home visits.[1] Highlighted below are key documentation and coding changes for facility and home-based E/M CPT codes, along with other impending changes to facility E/M services co-rendered by physicians and non-physician practitioners (“NPP’s).
RELAXED DOCUMENTATION REQUIREMENTS
January 2021 marked a significant shift in the documentation requirements for office and outpatient E/M levels 2 through 5. Further revisions are now forthcoming which will more closely align non-office E/M encounters with the prior changes adopted in 2021 which has been a source of confusion for providers working in both the office and facility settings.
A welcome change is the relaxation in the requirements surrounding history and physical exam (“H&P”) such that these elements will no longer be utilized to select the level of E/M visit in any service setting. Rather, H&P elements for the remaining E/M family of codes will only be considered to the extent they are medically appropriate and will not impact the level of service.
Specific to the inpatient E/M codes, effective January 1, 2023, Medicare proposed adopting the AMA revisions whereby visit levels will be selected based on practitioner time or the level of medical decision making (“MDM”) alone. Per a revised Table of Medical Decision Making put forward by the AMA, the level of MDM will be determined based on two of three elements:
1. Complexity of problems (s) addressed.
2. Data reviewed and analyzed.
3. Risk of patient management or treatment options.
With the exception of E/M services reported in the emergency department, total time of the rendering practitioner can be utilized for selecting the E/M level in all other settings. This includes face-to-face time and non-face-to-face patient time per the list of qualifying activities adopted previously into the E/M CPT framework for office and outpatient E/M services.[2]
2023 E/M CODE-SET CHANGES
Impending guidelines not only simplify documentation requirements but also streamline CPT code selection for practitioners working in non-office settings, significantly reducing the number of codes.
In total, twenty-five (25) codes have been removed from the E/M family with proposed key revisions summarized below:
Inpatient and observation E/M codes have been consolidated into a single code set. Hospital inpatient and observation care by physicians will be billed using CPT codes 99221 through 99223, 99231 through 99233, and 99238-99239. Code descriptors, including service times, are changing. Observation CPT codes 99218-99220, 99224-99226, and 99217 will be deleted.
Emergency Department Services will be determined only based on MDM under the new E/M framework. The AMA has indicated because emergency department services involve multiple encounters with patients over an extended period, time will not be a descriptive component for utilization within this code set.
Nursing and SNF E/M services may be reported using MDM or time, but codes have new time descriptors. Also, the nursing facility care code CPT 99318 will go dormant. Medicare is proposing utilizing the initial nursing facility care code set (CPT codes 99304 through 99306) for the initial comprehensive assessment.
Home and domiciliary care visits have been combined into a single code set. Code descriptors are changing, and these services will be reported with Home or Residence Services CPT codes 99341-99345 and 99347-99350 utilizing either medical decision making or time.[3]
SPLIT (OR SHARED) SERVICES
Recording time for E/M services may not be something practitioners are accustomed to and while new code descriptors and E/M guidelines facilitate the process, E/M services shared between a physician and NPP in the hospital, or other facility setting, will require capturing time. This will be a new workflow consideration, requiring precise total time to support billing by the physician of a split/shared service. Without support, facility E/M encounters will be subject to a fifteen percent (15%) payment adjustment when co-rendered by a physician and NPP.
Guidance surrounding split (or shared) E/M services was withdrawn from the Medicare Claims Processing Manual in May 2021 in response to a petition under the Good Guidance regulation.[4] Historically, the challenge with the split (or shared) service criteria has been defining the substantive portion of the service shared between an NPP and physician.
Under the updated guidance, “substantive” has been defined by CMS as the practitioner rendering more than half of the total aggregated time and to determine total time, the distinct time of the service spent by each physician or NPP furnishing a split (or shared visit) will now be summed.
While the CY 2022 PFS stipulated implementing the new provisions in 2023, proposed rulemaking for Calendar Year 2023 has delayed the implementation, allowing additional time to transition clinical workflows, practice patterns, and information systems to accommodate capturing time. As currently proposed, time must be documented by both the NPP and Physician to effectively determine the substantive portion of a shared visit effective January 1, 2024.[5] Some additional important points:
To facilitate claim identification, Modifier -FS must be appended to split shared E/M visits, even during the transition period.
Until Calendar Year 2024, one (1) of three (3) documentation components can support the substantive portion of the service: history, exam or MDM. Alternatively, time can be utilized meaning more than half of the total time spent by the physician and NPP performing the split (or shared) may determine the billing practitioner.
CMS is explicit relative to distinct time to mitigate the potential for aggregating overlapping time. When the NPP and physician jointly meet with or discuss the patient, only the time of one individual can be counted.
CMS has defined the activities that could count toward total time for the purposes of determining the substantive portion of a shared E/M service. Drawing on CPT guidelines for outpatient E/M services, this list includes both face-to-face and non-face to face services, as follows:
Preparing to see the patient (review of tests, etc.)
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(not separately reported) and communicating results to the patient/ family/caregiver
Care coordination (not separately reported)
CMS finalized that the substantive portion can be comprised of time that is with or without direct patient contact. In other words, if the physician spends more time than the NPP rendering non-face-to-face aspects of the service, the physician may be the billing provider. Of course, there must be direct patient contact by the NPP in this scenario, but it is plausible that the physician spends more time synthesizing test results, collaborating with other providers and counseling the family.
Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion, and therefore bills, must sign and date the medical record.[6]
SunStone is encouraging hospitals and health systems to educate practitioners, evaluate workflow and consider how capturing time will impact practice patterns in the facility setting. To facilitate proper billing, it is vital to consider credentialing NPP’s with Medicare and other payers that are updating their policies based on the new guidance prior to the January 2024 implementation. Initiating enrollment of NPP’s well in advance will support compliance and mitigate potential for delays in reimbursement.
To assist our clients, manage the E/M changes prescribed in the proposed rule, SunStone is offering a free Webinar on November 10, 2022 at 12:00pm Eastern Standard Time. We will discuss the new rule, pitfalls identified during the 2021 E/M office and outpatient changes, as well as provide tips for evaluating templates within the Electronic Health Record. To register for the session, please email the following:
SunStone Consulting offers comprehensive services geared to help professionals, hospitals and health systems evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact Vonda Moon, Senior Principal, Joli Fitzgibbons, Director, or Cathy Archuleta, Senior Manager.
[1] CMS Physician Fee Schedule Proposed Rule 2023, Federal Register Vol.87, No. 145/Friday, July 29, 2022/Evaluation and Management (E/M) Visits, page 127. <https://www.govinfo.gov/content/pkg/FR-2022-07-29/pdf/2022-14562>
[2] AMA CPT Evaluation and Management (E/M) Code and Guideline Changes, page 20. < https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf>
[3] AMA CPT Evaluation and Management (E/M) Code and Guideline Changes, pages 22-36. < https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf>
[4] CMS Notice Regarding Split (or Shared) Evaluation and Management Visits and Critical Care Services from May 25, 2021 through December 31, 2021 <https://www.cms.gov/files/document/enf-instruction-split-shared-critical-care-052521-final.pdf>
[5] CMS Physician Fee Schedule Proposed Rule 2023, Federal Register Vol.87, No. 145/Friday, July 29, 2022/Evaluation and Management (E/M) Visits, page 144. <https://www.govinfo.gov/content/pkg/FR-2022-07-29/pdf/2022-14562>
[6] CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.18 – Split (or Shared) Visits., page 64, <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm14c12.pdf>