General Surgery Coding Alert

See which codes may impact general surgery practices.

Even if you’ve finally gotten used to reporting office/outpatient evaluation and management (E/M) services under the revised CPT^® 2021 guidelines and codes, you’ll need to ramp up your know-how to change your reporting for dozens of other E/M codes in 2023.

Backstory: During 2021 and 2022, CPT^® featured two different ways to calculate levels for office/outpatient E/M services 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …):

• By meeting or exceeding two of the three MDM elements: the number and complexity of problems addressed at the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.
• By assigning a level based on the total time the provider has spent on face-to-face and non-face-to-face activities as defined by CPT^® guidelines.

For the remaining E/M service categories, you’ve been calculating E/M levels using the old 1995/1997 documentation guidelines, using history, exam, and/or MDM or time, when appropriate, by applying the 50 percent counselling and/or coordination of care guideline.

Greet CPT^® 2023 E/M Changes

As of Jan. 1, many code deletions, revisions, and additions give you new ways to select codes for other E/M categories besides office/outpatient E/M.

Multiple E/M code changes are likely to impact general surgery practices in the new year. For the following codes, the 2023 changes indicate that the provider must document a medically appropriate history and/or examination, but select the code based on the level of medical decision making (MDM) or total time (face-to-face and non-face-to face).

• Delete observation codes 99217-99220 (… observation care…)
• Revise the following codes to describe inpatient or observation care:

o 99221-99239 (Initial hospital inpatient or observation care, per day …)

o 99231-99233 (Subsequent hospital inpatient or observation care, per day …)

o 99234-99236 (Hospital inpatient or observation care… including admission and discharge on the same date …)

• Delete 99241 (Office consultation …)
• Revise 99242-99245 (Office or other outpatient consultation …) (Note: For a fuller discussion of these codes, see “Hone Your Office/Outpatient Consultation Coding Skills for 2023” in General Surgery Coding Alert Vol. 24 No 11)
• Delete 99251 (Inpatient consultation for a new or established patient…)
• Revise 99252-99255 (Inpatient or observation consultation for a new or established patient …)

CPT^® 2023 also revises 99282-99285 (Emergency department visit …) to require an appropriate history and/or examination, but you will select the code based on the level of MDM without the option to code by time.

More revisions to other E/M categories are less likely to impact general surgery coders, such as codes for E/M services provided in nursing facilities, homes, and domiciliary rest homes.

Refresh Rules for MDM or Time Reporting

With the code revisions that allow you to base your code selection on MDM, several factors influence the service level. MDM levels will not depend on whether the patient is experiencing multiple new or established conditions at the time of the encounter, but whether those conditions are acute or chronic. “2023 MDM is similar to the 2021 rules in that the new or established conditions do not matter as much as whether those problem were addressed and managed,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Extra: Selecting the level of MDM requires more than determining the number and complexity of problems addressed at the encounter. “With the revised MDM calculations, the coder must also consider the amount or complexity of data to be reviewed and analyzed, as well as the risk of complications or morbidity or mortality of patient management. Two of these three areas must meet or exceed the requirements for any given level in order to assign an E/M code,” says Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager at EisnerAmper Advisory Group in Iselin, New Jersey.