Background: Big Changes from 2021
The Evaluation and Management (E/M) codes have been based on the 1995 and 1997 E/M Guidelines for what seemed like forever. The E/M codes were based upon three key components: 1) the history, 2) the examination, and 3) medical decision making all performed at the proper levels. On January 1, 2021, everything changed. The changes were specific to Evaluation and Management services that were performed in the office or other outpatient places of service only. Clinicians are now able to use either time or medical decision making to select an E/M code. There is no required level of history or examination for the E/M codes.

Now: Highlights for 2023
On January 1, 2023, the changes that were made to E/M services that were performed in the office or other outpatient places of service were expanded to the other places of service. The E/M codes include a medically appropriate history and/or examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or the patient caregiver may supply information directly (e.g., by electronic health record HERR) portal or questionnaire that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in the selection of the level of these E/M codes.

Time is defined as total time spent, including non-face-to-face work done on that day and no longer requires time to be dominated by counseling. It includes time regardless of the location of the physician or other qualified health care professional (e.g., whether on or off the inpatient unit or in or out of the outpatient office). It does not include time spent in the performance of other separately reported service(s).

The definitions of medical decision making (MDM) are the same as the definitions of medical decision making that went into effect for office and other outpatient places of service on January 1, 2021.

TO REVIEW A COMPREHENSIVE LIST  OF CODING CHANGES, CLICK HERE!

If you aren’t currently insured with PICA, take a moment to reevaluate your decision. Fill out our online form to get a no-obligation quote.

The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.