Effective January 1, 2023, AMA has announced the following changes in Evaluation and Management (E/M) Code and Guidelines for 2023.
- E/M Introductory Guidelines related to Hospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations codes 99242- 99245, 99252-99255, Emergency Department Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315, 99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-99350.
- Deletion of Hospital Observation Services E/M codes 99217-99220.
- Revision of Hospital Inpatient and Observation Care Services E/M codes 99221-99223, 99231-99239, and guidelines.
- Deletion of Consultations E/M codes 99241 and 99251.
- Revision of Consultations E/M codes 99242-99245, 99252-99255, and guidelines.
- Revision of Emergency Department Services E/M codes 99281-99285 and guidelines.
- Deletion of Nursing Facility Services E/M code 99318.
- Revision of Nursing Facility Services E/M codes 99304-99310, 99315, 99316 and guidelines.
- Deletion of Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services E/M codes 99324-99238, 99334-99337, 99339, 99340.
- Deletion of Home or Residence Services E/M code 99343.
- Revision of Home or Residence Services E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines.
- Deletion of Prolonged Services E/M codes 99354-99357.
- Revision of guidelines for Prolonged Services E/M codes 99358, 99359, 99415, 99416.
- Revision of Prolonged Services E/M code 99417 and guidelines.
- Establishment of Prolonged Services E/M code 993X0 and guidelines.
Evaluation and Management (E/M) Code and Guideline Changes for Emergency Department:
Guidelines for Selecting Level of Service Based on Medical Decision Making
Four types of MDM are recognized: straightforward, low, moderate, and high. The concept of the level of MDM does not apply to 99211, 99281.
MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM is defined by three elements. The elements are:
- The number and complexity of problem(s) that are addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management.
Guidelines for Hospital Observation Services
Observation Care Services (Including Admission and Discharge Services)
99234 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same
date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making.
When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99235 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same
date, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.
99236 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same
date, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.
Initial Observation Care
(99218, 99219, 99220 have been deleted. To report initial observation care, new or established patient, see 99221, 99222, 99223)
99221 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and straightforward or low level medical decision making.
When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99222 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and moderate level of medical decision making.
When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
99223 Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate
history and/or examination and high level of medical decision making.
When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
(For services of 90 minutes or longer, use prolonged services code 993X0)
Subsequent Observation Care
(99224, 99225, 99226 have been deleted. To report subsequent observation care, see 99231, 99232, 99233)
99231 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making.
When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
99232 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically
appropriate history and/or examination and moderate level of medical decision making.
When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
99233 Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically
appropriate history and/or examination and high level of medical decision making
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.
(For services of 65 minutes or longer, use prolonged services code 993X0)
Observation Care Discharge Services
(99217 has been deleted. To report observation care discharge services, see 99238, 99239)
99238 Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter
99239 more than 30 minutes on the date of the encounter
(For hospital inpatient or observation care including the admission and discharge of the patient on the same date, see 99234, 99235, 99236)
(For discharge services provided to newborns admitted and discharged on the same date, use 99463)
Note: These changes will only apply on the physician claims (Professional CMS-1500).
To learn more in detail about the changes announced by AMA. Review this document published by AMA.
CPT® Evaluation and Management (E/M)Code and Guideline Changes effective January 1, 2023