Examining the 2023 proposed rule changes for E/M visits

Oct. 24, 2022 / By Jean Jones, CPC, Cecilia Charles, RHIA

Evaluation and Management (E/M) services is our favorite topic to blog about. Our team submitted a blog prior to the new 2021 changes that was about the new guidelines at the time. Now, two years later, we are blogging about the 2023 guideline changes for several categories of E/M services. In discussing the new guidelines, one of our clients told us about how excited they were for the changes. It still feels like a paradigm shift to go from guidelines that we have used since the 1990s to our new guidelines. 

Before we dive into the proposed changes, we wanted to provide an update to my August 2022 blog. We asked clinicians to weigh in on whether they were using the 2021 E/M guideline change. We anticipated our next blog was going to be about the barriers preventing clinicians from taking advantage of the guideline change, but now we have a topic that takes precedence. To close the gap, we wanted to mention the barrier we hear most about in preventing guideline adherence: template changes. 

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule changes for E/M visits to go into effect on Jan. 1, 2023.  

These changes in the E/M guidelines cover specific for codes 99202-99499, and are divided into following categories: 

  • Office or other outpatient services 
  • Hospital inpatient and observation care services 
  • Consultations 
  • Emergency department services 
  • Nursing facility services 
  • Home or residence services 
  • Prolonged service with or without direct patient contact on the date of an E/M service 

Most of the E/M categories are further divided into subcategories for E/M services, such as new patient and established patient, two subcategories of hospital inpatient and observation, as well as initial and subsequent. We are now using the 2021 methodology of leveling service to be rolled out to all the categories in E/M that have key components. The appropriate level of E/M services will be based on:  

  • Level of medical decision making (MDM) for each service, or 
  • The total time for E/M services performed on the date of the encounter.  

The guidelines for selecting level of service based on MDM is defined by three elements: 

  • 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 

Leveling based on time only requires the total time of the encounter. This is for coding purposes only. Time can include: 

  • Preparation for the visit 
  • Obtaining and/or reviewing history 
  • Counseling patient and family members 
  • Ordering tests 
  • Coordinating care 

Be aware that the time element does not apply to emergency room services CPT® 99282-99285.   

It is an exciting time in health care and in 2023 all the E/M codes (except for emergency medicine category) that once had three key components will now be leveled based on MDM components or time. 

The guidelines do state that a medically appropriate history and exam should be documented. 

We have all heard about clinician burnout and it is my hope that these changes will reduce the documentation burden that the clinicians feel.   

Jean Jones is a coding analyst at 3M Health Information Systems. 

Cecilia Charles, RHIA, is a coding analyst manager at 3M Health Information Systems.