One of the biggest changes in the 2023 E/M guidelines will be a shift away from billing by history and physical exam to code levels that are now based on medical decision making and time, matching the previous documentation update for ambulatory services made in 2021.1
Along the same line, clinicians are no longer required to document a certain number of systems, past medical and family history and other information that may not be immediately relevant to active patient problems. A “medically appropriate history and physical” is still required but it no longer has a role in code selection. If you use time-based billing, you are no longer required to document just the time spent on counseling and/or coordination of care but make sure to document all the work you performed on the date of the encounter.
Another notable change is collapsing of the observation CPT codes into the inpatient codes, so you should bill the same code for patients regardless of whether they are inpatient or observation.
The Medical Decision Making (MDM) table is also shifting to align with the office/outpatient table. Recall that the MDM is comprised of 3 domains: 1. Number and complexity of problems addressed at the encounter; 2. Amount and/or complexity of data to be reviewed and analyzed: and 3. Risk of complications and/or morbidity or mortality of patient management (for further information see also a relate Pearl).
One good thing that may come out of these changes is a move away from unnecessary “note bloat” with several pages that usually has very little relevance to the active patient problems or what is actually done each day. Hopefully, these changes will encourage providers to better document their medical decision making, and the time spent doing it.
In short, when writing your notes, make sure you clearly address the most important question: “What did I do for this patient today?” 1
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- Quinn R. E/M coding changes for 2023. The Hospitalist 2023; 27: 10. E/M Coding Changes for 2023 – The Hospitalist (the-hospitalist.org)
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