E/M 2023 Guideline Revisions Impact/FAQs
impact of the 2023 E/M guideline revisions
We are now over a year out from the release of the 2023 AMA revised guidelines for E/M categories including hospital, observation, inpatient/outpatient consultations, emergency department, nursing facility and home/residence services. The revision of guidelines for these services provides consistency with the revisions that were implemented in 2021 for the office and outpatient E/M services. The goal was to reduce the burden of documentation and the note bloat that was occurring due to the check-box nature of meeting the documentation requirements. Per the AMA, “Documentation for E/M services will now be centered around how physicians think and take care of patients and not on mandatory standards that encouraged copy/paste and checking boxes.”
Was the goal achieved? As coders and auditors are you seeing documentation that is leading to improved patient care and relief of documentation burden on providers? I believe these are both possibilities, but it will require more feedback and time to accomplish the goal. Providers are getting used to moving from the required text box method that has consumed their time and documenting pattern for years. They are now focusing on the narrative that adequately describes their thought process for medical decision making and describing the acuity of the illness and risk involved in management or treatment they are considering. Because documentation is reviewed by and utilized by non-clinical people a descriptive narrative is vital.
It is common for questions to arise after the implementation of new or revised guidelines.
E/M guideline revisions FAQs
1) Under Risk of Complications and/or Morbidity or Mortality of Patient Management, High Risk Category there is the example of “Decision regarding hospitalization or escalation of hospital level care”. If the patient is seen in the ED and then admitted by a hospitalist who gets credit for the decision to hospitalize?
The answer is simple but can be more complicated if the documentation is not adequate. Which provider is doing the work? Which provider is making the decisions regarding hospitalization? If the ED provider is making the decision or recommendation, and the hospitalist is not consulting but documenting the action of admitting based on the ED provider’s request. Then the ED provider would get credit for the decision to hospitalize, and the hospitalist would get credit based on the MDM they document (excluding the decision regarding hospitalization). This scenario represents a hand off or transition in care.
Per CPT “Examples in the table may be more or less applicable to specific settings of care. For example, the decision to hospitalize applies to the outpatient setting or nursing facility encounters, whereas the decision to escalate hospital level care (eg, transfer to ICU) applies to the hospitalized or observation care patient.”
Also note the wording is “Decision Regarding Hospitalization” not Decision to Hospitalize. The provider receives credit for their thought process that leads to the final decision. They may consider hospitalization and the patient may choose palliative care or refuse admission. If adequately documented credit would apply for “Decision Regarding Hospitalization” even if that is not the end result.
2) Is there a list of drugs that require intensive monitoring for toxicity and if so can credit for high risk be given if those drugs are ordered and monitoring is not documented?
There is not a comprehensive list from CMS or AMA. However, you may find guidance from the applicable MAC or payer. Most importantly the provider should state why the drug is toxic and what they are doing to monitor it. Some drugs may prove toxic to one patient but not all. This makes it very difficult to create a comprehensive list. Coders should not assume tests or labs documented indicate intensive monitoring. Documentation should paint a clear picture of the risk of toxicity and measures taken to monitor it.
“Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.”
https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
3) Should a coder or auditor determine if a patient’s medical illness is stable or worsening?
Often documentation does not clearly indicate the status of diagnosis. This is inadequate documentation. A coder or auditor should not be searching for indicators in the record that would allow the assumption of the status. Per the AMA, “The patient’s physician or other QHP is expected to determine whether the medical problem or illness is stable or worsening. A problem is addressed or managed when it is evaluated and/or treated at the encounter by the physician or other QHP reporting the service.”
If not indicated in the documentation it is an opportunity to query the provider. Documentation education is recommended if it is a reoccurring insufficiency.
4) If the patient has several acute stable or uncomplicated illnesses should this be considered moderate under THE Number and Complexity of Problems Addressed?
No, the volume of illnesses is not the deciding factor between Low and Moderate. The severity of the illness leads to a higher level on the EM Grid. Moderate requires an acute illness with systemic symptoms. Refer to the AMA definitions below. Notice the stable, resolving nature of the first three that fall under low compared to an acute illness with systemic symptoms that has a high risk of morbidity without treatment.
Acute, uncomplicated illness or injury: A recent or new short-term problem with a low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistently with a definite and prescribed course is an acute, uncomplicated illness.
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation-level setting.
Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problems or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be a single system.
Keep in mind that if additional time is required to address the multiple illnesses the provider could consider documenting total time and determining if that is the best option to use for code selection.
5) Is there a significant decrease in the amount of subsequent 99233’s since the revisions took place Jan 2023?
Official reporting is not available yet, but I have had several clients and colleagues bring up this concern. I have also experienced this across individual facilities. However, leaders in the industry agree that guideline revisions and outcomes fairly represent the level of service needed and being provided. The intent was not to drastically change the levels. It is likely that over-coding was occurring based on the check box methodology of documenting.
The best support we can give providers is continual feedback and documentation education, encouraging descriptive narratives allowing the documentation to adequately describe the level of service they are providing patients
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