Gastroenterology Coding Alert

Also: decipher a discrepancy between CPT^® and CMS.

As you’ll recall, CPT^® overhauled the inpatient/hospital evaluation and management (E/M) codes in 2023, which came on the coattails of a similar shake-up of the office/outpatient E/M codes in 2021.

To make sure you’re on the path to coding success, let’s review the 2023 E/M changes, address common confusion surrounding those changes, and look ahead and what you can expect in 2024.

Recall the 2023 Code Changes

Like the 2021 updates to the office/outpatient E/M codes, the 2023 inpatient/hospital E/M changes affected the weights given to history, examination, and medical decision making (MDM) in determining the level of E/M service. A time component was also added to the descriptors to indicate that the coder could use time or MDM as the sole deciding factor when choosing an E/M service code.

The update affected 99221 (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 and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded) as well as 99234-99236 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low/moderate/high level of medical decision making. When using total time on the date of the encounter for code selection, 45/70/85 minutes must be met or exceeded.).

This change, in turn, created the need for CPT^® to delete 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity…) through 99220 (…high complexity...), as well as discharge management code 99217 (Observation care discharge day management…).

Overcome Lingering Confusion Around 2023 Guideline Changes

Even though many GI coders are growing more comfortable with these changes, there is residual frustration regarding how to report initial hospital care when multiple GI providers see the patient during the admission.

Why: Historically, only the admitting physician was able to use the initial hospital care codes 99221-99223, explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

CPT^® 2023 E/M guidelines state: “An initial service may be reported when the patient has not received any professional services from the physician or other qualified health care professional (QHP) or another physician or QHP of the exact same specialty and subspecialty who belongs to the same group practice during the stay.”

Also per CPT^®, “when the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.”

This means submitting a single initial hospital admission or observation code per patient, no matter the number of providers if from the same specialty and practice treating the patient. “CPT^® clarifies in the 2023 E/M guidelines that a hospital admission is from when the patient is admitted until when the patient is discharged,” says Falbo. “That’s one course of admission, so they [the payers] would expect to see only one initial code for that course of stay from practitioners of the same specialty and subspecialty who belong to the same group practice. This is an adjustment,” Falbo says.

But: While the CPT^® policy has changed, the Centers for Medicare & Medicaid Services (CMS) policy has not. Per CMS, “… when a patient is admitted to outpatient observation or as a hospital inpatient via another site of service (such as hospital ED, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital inpatient or observation care when performed on the same date as the admission. This policy differs somewhat from the instructions provided in the 2023 CPT^® Codebook.”

Best practice: To help avoid double-dipping on initial observation care claims, be sure to check with the payer and confirm their preferences in these situations.

For more information, check out the Medicare Claims Processing Manual, IOM 100-04, Chapter 12, 30.6.9.1.A.

Look Toward Office/Outpatient Time Changes in 2024

This year’s office/outpatient E/M changes are minimal, but that doesn’t mean they are insignificant. CPT^® has decided to remove the time ranges from both the new and established office/outpatient E/M code descriptors and replace them with a single time that “must be met or exceeded.”

For example, 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) has a current time range of 15-29 minutes. However, beginning Jan. 1, 2024, the provider must meet or exceed 15 minutes of total service time before you can bill this code by time.

Note: CPT^® will not be changing the descriptor to 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional), which you will continue to bill for established patients receiving E/M services from a nurse practitioner (NP), a physician assistant (PA), or any other nonphysician practitioner (NPP). The code will also continue to require no level of medical decision making (MDM) or total time for you to document.

Remember: Total time will still include face-to-face time as well as time the physician and/or qualified healthcare professional (QHP) personally spent on the patient’s care on the day of the encounter. But “it does not include time spent in the performance of separately reported services,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, NV during his session “E/M Audits for Primary Care” during HEALTHCON Regional 2023 in Washington, DC.