The American Medical Association (AMA) has released changes to the CPT Evaluation and Management (E/M) codes and guidelines, set to go into effect Jan. 1, 2023. These changes build on the revisions to office/outpatient E/M codes in 2021 that emphasized medical decision-making and sought to reduce documentation burden. These E/M changes will affect hospital inpatients, observation care visits, consultations, emergency room visits, nursing facility services along with home, rest home, and domiciliary E/M codes.

Highlights include:

• Level of E/M services will be based on the following:
  
  
  • The level of the MDM as defined for each service

OR

• The total time for the E/M service performed on the date of the encounter
  
  • Time spent by the practitioner includes face-to-face and non-face-to-face time
    
    
• History and exam no longer used to select the level of code
  
  
• Revision/combining of Hospital Inpatient and Observation Care Services E/M codes 99221-99223, 99231-99239 and guidelines (one code combines both services)
  
  
  • Hospital Observation Services E/M codes were deleted
    
    
  • Inpatient Hospital Services E/M codes were revised to include Observation Care Services
    
    
• Changes to the Prolonged Services Codes
  
  
• Centers for Medicare and Medicaid Services (CMS) proposed Prolonged Services Codes

In addition, within the proposed 2023 Medicare Physician Fee Schedule rule, the Centers for Medicare and Medicaid Services (CMS) has proposed to adopt most of these CPT revisions, although some discrepancies remain.

Of note, the proposed rule includes updates to work and/or practice expense (PE) values for codes describing E/M services, External Extended ECG Monitoring, and Cardiac Ablation. The agency would adopt changes to several E/M code families, including hospital, emergency medicine, nursing facility and home visits, as recommended by the CPT Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC). Additionally, the rule includes proposed work and PE values for new/revised codes describing Endovascular Pulmonary Arterial Revascularization and Pulmonary Angiography.

However, CMS does not agree with the AMA regarding the use of Prolonged Service Codes. Prolonged Services CPT codes 99358, 99359, 99415 and 99416 have new guidelines and 99417 has been revised. CMS instead proposes its own prolonged service codes: GXXX1 for use with initial IP/Obs. visit; subsequent IP/Obs. visit; or IP/Obs. same-day admission/discharge visit. CMS has created GXXX2 for prolonged services for use with initial and subsequent NF visits and GXXX3 for use with home/residence visits for new and established patients.

CMS also proposes to not adopt the general CPT rule where a billable unit of time is considered to have been attained when the midpoint is passed (for example, the agency would not consider a service with a time descriptor of 30 minutes to have been satisfied if only 15 minutes of time had been spent furnishing that service).

Clinical Topics: Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension

Keywords: Electrocardiography, Hospitals, Physicians, Angiography, Emergency Medicine, Clinical Decision-Making, Emergency Service, Hospital, Referral and Consultation, Fee Schedules, Patient Discharge, Outpatients, Hypertension, Pulmonary, House Calls, American Medical Association, Medicare, Inpatients, Centers for Medicare and Medicaid Services, U.S., Current Procedural Terminology, United States, Aged, ACC Advocacy

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