The American Medical Association (AMA) has recently released the Current Procedural Terminology (CPT) code set for 2023, which contains updates that aim to reduce the medical coding burden for evaluation and management (E/M) visits. In this article, out of all Evaluation and Management (E/M) guidelines, we will be focussing on revised guidelines for office visits. It includes defining, new and established patients; initial and subsequent services; and services reported separately. Let’s understand the basic classification of Evaluation and Management (E/M) services before discussing revised guidelines for office visits.
The E/M section is divided into broad categories, such as office visits, hospital inpatient or observation care visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital inpatient and observation care visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes.
The basic format of codes with levels of E/M services based on medical decision-making (MDM) or time is the same. First, a unique code number is listed. Second, the place and/or type of service is specified (e.g., office or other outpatient visits). Third, the content of the service is defined. Fourth, time is specified. The place of service and service type is defined by the location where the face-to-face encounter with the patient and/or family/caregiver occurs. For example, service provided to a nursing facility resident brought to the office is reported with an office or other outpatient code.
Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.
New Patient: A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
In the instance where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. Note that, no distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
Some categories apply to both new and established patients (e.g., hospital inpatient or observation care). These categories differentiate services by whether the service is the initial service or a subsequent service. For the purpose of distinguishing between initial or subsequent visits, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.
Initial Service: An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stays.
Subsequent Service: A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stays.
In the instance when a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. For reporting hospital inpatient or observation care services, a stay that includes a transition from observation to inpatient is a single stay. For reporting nursing facility services, a stay that includes transition(s) between skilled nursing facility and nursing facility level of care is the same stay.
The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.
The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (i.e., professional component) with the preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.
The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.
To discuss revised guidelines for office visits, we referred to ‘2023 CPT E/M descriptors and guidelines published by American Medical Association (AMA). Note that these guidelines are to be used by the reporting physician or other qualified healthcare professional to select the appropriate level of service. These guidelines do not establish documentation requirements or standards of care. The main purpose of documentation is to support the care of the patient by current and future healthcare team(s). These guidelines are for services that require a face-to-face encounter with the patient and/or family/caregiver.
We hope this article has given you a good understanding of revised guidelines for office visits, you can visit the AMA reference link for a detailed understanding. If you are busy in patient care and can’t keep track of E/M coding updates, we can assist you. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services.
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CPT Copyright 2022: American Medical Association
