Remember the overwhelming changes to evaluation and management (E/M) coding for exams and most outpatient services that happened in 2021? The same types of changes are being applied in 2023 for other E/M codes.

While most ophthalmology practices mainly focus on office-based E/M services, other services are also provided.

Q. What codes should we expect to be changed?

A. The American Medical Association (AMA), author of CPT, recently released advance notice of changes to the E/M codes for hospital visits, inpatient and outpatient consultations, nursing facility services, home visits and prolonged services codes.

Q. What changes should we expect?

A. The changes to inpatient visit codes largely mirror those we’ve already become accustomed to for outpatient visit codes, but with some exceptions. Here is an overview of specific codes that are pertinent to ophthalmology:

• Hospital Inpatient and Observation Services codes 99217-99239
  • Delete Hospital Observation codes 99217-99220
  • Hospital Inpatient codes 99221-99239 will be used for both inpatient and observation patients
• Consultation Codes, both outpatient and inpatient 99241-99255
  • Delete Consultation codes 99241 and 99251 (consistent with other outpatient codes, level 1 codes are omitted)
  • Revise Consultation codes 99242-99245 and 99252-99255
• Emergency Department Services 99281-99285
  • Revise Emergency Department codes 99281-99285
• Nursing Facility Services 99304-99318
  • Delete Nursing Facility code 99318
  • Revise Nursing Facility codes
• Domiciliary, Home or Residence Services 99324-99350
  • Delete Domiciliary, Rest Home or Custodial Care codes 99324-99328, 99334-99337, 99339 and 99340
  • Revise Home or Residence codes 99341-99345, 99347-99350
• Prolonged Services 99354-99359, 99415-99417
  • Delete Prolonged Services codes 99354-99357
  • Revise guidelines for Prolonged Services codes 99358-99359, 99415-99417
  • Establish new prolonged Services code 993x0

Q. So, what changes for the coding guidelines?

A. As noted, coding for services listed above will usually be based on medical decision making (MDM). That is, the number and complexity of problems addressed at the encounter will largely drive the coding. The number of elements of history and/or exam will not be relevant for these codes, just as we’ve become accustomed to with office-based exam codes.

The other approach to determine a proper code for an encounter will be based on physician time on the day of the encounter. We’ve learned that for most ophthalmology patient encounters, time is not the driving factor; most encounters will be based on MDM.

Q. What are some examples?

A. Let’s look at hospital inpatient visit coding. Three codes describe the initial hospital inpatient or observation care:

• “Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …”
  • 99221 “… and straightforward or low-level medical decision making.”
  • 99222 “… and moderate level of medical decision making.”
  • 99223 “… and high level of medical decision making.”

When coding based on physician time, the pertinent spans for each of the above codes are 40, 55 and 75 minutes, respectively. You can see why most ophthalmology visits are based on MDM.

For subsequent hospital inpatient coding, an additional three codes apply:

• “Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination … “
  • 99231 “… and straightforward or low-level medical decision making.”
  • 99232 “… and moderate level of medical decision making.”
  • 99233 “… and high level of medical decision making.”

When coding based on physician time, the pertinent spans for each of the above codes are 25, 35 and 50 minutes, respectively.

Nursing facility visits are another example:

• “Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …”
  • 99304 “… and straightforward or low-level medical decision making.”
  • 99305 “… and moderate level of medical decision making.”
  • 99306 “… and high level of medical decision making.”

When coding based on physician time, the pertinent spans for each of the above codes are 25, 35 and 45 minutes, respectively.

Similar instructions apply to emergency room and home visits.

Q. What is the take-home lesson?

A. In 2021, coding for E/M office-based services changed. The changes simplified documentation requirements considerably, in that they required “medically appropriate” history and examinations. We no longer have to count elements of the history or exam.

In 2023, the AMA is expanding the documentation requirements to other E/M services. While these facility-based services are not a common part of most ophthalmic practices, they do occur.

We will be pleased at the simpler documentation requirements for these codes as well. OM

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .