Billing

What are the major changes in the 2023 evaluation and management (E/M) coding guidelines affecting the hospitalists?

FA Manian MD, MPH, , , , , , , Leave a comment

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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Reference

  1. Quinn R. E/M coding changes for 2023. The Hospitalist 2023; 27: 10. E/M Coding Changes for 2023 – The Hospitalist (the-hospitalist.org)

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

What are the major changes in the 2023 evaluation and management (E/M) coding guidelines affecting the hospitalists?

What is the difference between “Moderate” and “High complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule?

FA Manian MD, MPH, , 1 Comment

The level of medical decision making (“Straightforward/Low complexity”, “Moderate complexity”, “High complexity”) or MDM should reflect the intensity of the cognitive labor performed by the clinician.

The MDM level is determined by 3 important factors:

  • The nature and number of clinical problems
  • The amount and complexity of data reviewed by the clinician
  • The risk of morbidity and mortality to the patient

As for the nature of clinical problems, in contrast to stable problems (1 point), the following receive higher points:

  • Established problems that are worsening (2 points)
  • New problems for which no further workup is planned (3 points)
  • New problems for which additional workup is planned (4 points)

As for the amount and complexity of data reviewed by the clinician, the following receive higher points (2 points each)

  •  Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
  • Independent visualization of image, tracing or specimen itself (not simply review of report)

More routine activities such as simply reviewing or ordering lab, radiology, or other tests, discussing tests results with performing physician, or obtaining old records and/or history from someone other than patient receive only 1 point each.

The 3rd element of MDM scoring system is based on the risk of complications and/or morbidity or mortality determined by the severity of the presenting problem(s), complexity of the diagnostic procedure(s) ordered, and management options selected.

Patients may be considered “High risk” of complications and/or morbidity or mortality when any of following is documented: 

A. Presenting problem(s)

  • ≥1 chronic illnesses with severe exacerbation, progression, or side effects of treatment
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure
  • An abrupt change in neurologic status, eg, seizure, TIA, weakness or sensory loss

B. Diagnostic procedure(s) ordered

  •  Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac electrophysiologic tests
  • Diagnostic endoscopies with identified risk factors
  • Discographies

C. Management options selected

  •  Elective major surgery (open, percutaneous or endoscopic with identified risk factors)
  • Emergency major surgery (open, percutaneous or endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

Less severe conditions such as pyelonephritis, pneumonitis, colitis, or head injury with brief loss of consciousness, and less complicated procedures such as diagnostic endoscopies and elective major surgery with no identified risk factor are considered “Moderate risk”.

 To qualify for “High complexity” care, at least 2 of the following must be present:

  • High (≥4 points) score in number of diagnoses or treatment option
  • High ((≥4 points) score in the amount and complexity of data gathered
  • High risk of complications and/or morbidity or mortality

Otherwise, your patient encounter qualifies for “Moderate” or lower complexity  care.

For further details on how to determine the MDM level on your individual patient go to:

https://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES

Contributed by Jodie Medeiros, CPC, COC, ICDCT-CM, Billing Specialist, Mass General Hospital, Boston, MA

 

What is the difference between “Moderate” and “High complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule?

What should I include in my hospital admission note to meet the criteria for “moderate” or “high-complexity encounter” as defined by the Centers for Medicare & Medicaid Services (CMS)?

FA Manian MD, MPH, , , Leave a comment

Aside from clearly documenting the chief complaint or reason for the encounter to establish medical necessity for your service,  certain history, exam and medical decision making elements in the admission note are required to support your billing.

Level 2 (moderate complexity) and 3 (high complexity) initial hospital care have the same comprehensive history and exam requirements. If a required history or exam element is lacking, the documentation would support a level 1 (low complexity) service. If you are attesting to an admission note by housestaff, make sure these elements are covered in either of your notes. 

A. HISTORY

Comprehensive history requires:
• Chief complaint
• An extended history of present illness 
• Complete (10 or more elements) review of systems
• Past medical, family and social history
Note: Phrases such as ‘family history deferred/unknown’, ‘review of systems as per HPI’ or ‘ROS negative’ are not acceptable substitutes.

B. EXAM

Comprehensive physical exam requires a minimum 8 of 12 organ systems listed below:
o Constitutional
o Eyes
o Ears, nose, mouth and throat
o Cardiovascular
o Respiratory
o Gastrointestinal
o Genitourinary
o Musculoskeletal
o Skin
o Neurological
o Psychological
o Lymphatic/hematologic/immunologic
Note: Body areas such as head, neck or extremities do not qualify as an “organ system”.

C. MEDICAL DECISION MAKING

Requires assessment, clinical impression or diagnosis and the plan for each problem managed.

Reference
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf 

 

Contributed by Jodie Medeiros CPC, COC, ICDCT-CM, Compliance Analyst & Educator, Mass General Hospital, Boston, MA

 

What should I include in my hospital admission note to meet the criteria for “moderate” or “high-complexity encounter” as defined by the Centers for Medicare & Medicaid Services (CMS)?