Neurosurgery Coding Alert

Read on to check out just what’s changing when you code your first ED E/M after the changes take effect on Jan. 1, 2023.

ED Changes Mirror Office E/M Changes … to a Point

As everyone knows, there were significant changes in the descriptors for office/outpatient E/M codes 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. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) in 2021.

CPT^® overhauled the descriptors for each of these codes, eliminating the language about three key components: history, examination, and medical decision making (MDM). In place of the three key components, CPT^® made time or MDM (one or the other, not both) the sole deciding factor in E/M level selection.

“For many years, professional medical associations have advocated to replace the contrived bulleted system of reporting E/M service levels based on the three ‘key components’ with one based on the primary worked performed by the physician: medical decision making,” explains Gregory Przybylski, MD, Immediate Past Chairman of Neuroscience and Director of Neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

The ED E/M revisions are reminiscent of those changes, with one big difference: the ED E/M codes will only allow coders to use MDM as the determining factor in code selection. This isn’t to say that you don’t need to document history or exam; but you don’t have to reach a certain level of history or exam (problem focused, straightforward, low, etc.) in order to select an ED E/M level. As the descriptor indicates, history and exam need to be “medically appropriate” for the encounter.

No time for time? It might seem odd to some that time thresholds were not included in ED codes — but it wasn’t an arbitrary decision. “This [decision] is based on the significant variability in time spent for each level of service that has been observed, making it difficult to identify a single threshold that would reflect the various types of encounters that occur at each level of service in the emergency department,” explains Przybylski.

Here’s What CPT^® Is Deleting

CPT^® 2023 will delete the descriptors for the following codes:

• 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making...)
• 99282 (… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity...)
• 99283 (… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity...)
• 99284 (… A detailed history; A detailed examination; and Medical decision making of moderate complexity...)
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity...)

Here’s What CPT^® Is Adding

CPT^® 2023 will add these descriptors for the above-listed codes:

• 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional)
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straight­forward medical decision making)
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making)
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making)
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making)

New Descriptors Provide Clarity, but Adjustment Could Hurt

Overall, experts think that the new 99281-99285 descriptors will positively impact ED coding — but perhaps not in the short term.

“We are grateful of the changes to the history and exam requirements are much more in line with clinical medicine,” explains Todt. “Additionally, we are looking forward to a more consistent approach to medical decision making.”

“Overall, I think I feel positive about these changes as they do away with some of the crazy documentation requirements: e.g., complete ROS [review of systems] in the ED,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “But I don›t think it will be intuitive for providers to document this way.”