Coding changes for E/M services - Provider
Coding and guidelines changes for E/M services, Jan. 1
The American Medical Association (AMA) recently issued extensive changes to CPT® evaluation and management (E/M) codes and guidelines. 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 code and guideline changes affect inpatient and observation care services, consultations, emergency department services, nursing facility services, home or residence services, and prolonged services.
In addition, the Centers for Medicare & Medicaid Services (CMS) released prolonged services codes for services rendered for Medicare Advantage members. This impacts both payers and providers.
- Coding changes impact psychiatrists and qualified health practitioners who perform E/M services and all provider types who perform prolonged services.
- Key elements of the E/M code changes impacting Magellan providers include:
- E/M guidelines related to hospital inpatient and observation care service codes, consultation codes, emergency department codes, nursing facility services codes, home or residence services codes.
- Level of E/M services is based on the level of medical decision making (MDM) as defined for each service or the total time for the E/M service.
- History and exam are no longer used to select the level of the code.
- Revision/combining of hospital inpatient and observation care services E/M codes 99221-99233 and 99231-99239 and guidelines.
- Hospital observation E/M codes were deleted.
- Inpatient hospital services E/M codes were revised to include observation care services.
- Revision/combining of domiciliary, rest home or custodial care E/M 99324-99338, 99334-99337 and home E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines.
- Domiciliary, rest home or custodial E/M codes were deleted.
- Home E/M codes were revised to include residence services.
- Revision of consultations E/M codes 99242-99245, 99252-99255 and guidelines; deletion of lowest level consultation codes 99241 and 99251.
- Revision of emergency department services E/M codes 99281-99285 and guidelines (time may not be used as a factor when selecting an ED visit).
- Revision of prolonged services E/M code 99417 and guidelines. In 2023, 99417 can be reported with outpatient E/M codes 99205, 99215 and with outpatient consult codes 99245, and home or residence codes 99345 and 99350.
- Addition of prolonged services E/M code 99418 and guidelines.
- Addition of prolonged services HCPCS codes G0316, G0317, G0318 for Medicare Advantage members.
- E/M guidelines related to hospital inpatient and observation care service codes, consultation codes, emergency department codes, nursing facility services codes, home or residence services codes.
Magellan is amending provider agreements to include new add-on codes for prolonged services to commercial reimbursement schedules.
Visit the AMA website for resource information, including videos and webinars.