Pulmonology Coding Alert

Know how to choose between MDM and time.

The evaluation and management (E/M) section of CPT^® is seeing more updates in calendar year (CY) 2023. Among the guidelines, headlines, and code revisions are changes to office/ outpatient consultations.

In this two-part series on 2023 office/outpatient consultation E/M codes, Pulmonology Coding Alert explains the changes that you will need to know about for the start of the new year.

Add 2021 E/M Rules to Consultations in 2023

Effective Jan. 1, 2023, you’ll see several changes in the American Medical Association’s (AMA’s) 2023 CPT^® E/M section, including revisions to inpatient and outpatient consultations. The changes to these subsections of the E/M chapter consist of headline, guideline, code, and descriptor adjustments that line up with the 2021 E/M rule changes to office and other outpatient visit codes 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) and 99211-99215 (… established patient …).

Starting off, the altered wording in the Consultations guidelines includes “other qualified healthcare professional” when mentioning who can perform E/M consultations as well as start diagnostic or therapeutic services during the visit or at a subsequent visit. Types of qualified healthcare professionals include, but are not limited to, physicians and advanced practice providers (APPs).

Turning to the office/outpatient consultations guidelines, you’ll find the places of service are revised in the 2023 code set:

• CY 2022: “…report consultations provided in the office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, or emergency department.”
• CY 2023: “…report consul­tations that are provided in the office or other outpatient site, including the home or residence, or emergency department.”

Mandatory modifier: The guidelines also state that you should append modifier 32 (Mandated services) to a consultation that is required. For example, if a payer requests a consultation, such as a second opinion before the payer approves treatment, you should append modifier 32 to the applicable consultation code.

AMA has released the 2023 changes to the E/M section early to help providers prepare. You can find the information at www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf. Keep in mind that you may still see some revisions to the code numbers and descriptors when the final code set comes out, but this information will help you get a jumpstart on preparations.

Revised Office/Outpatient Consultation Codes

In CY 2023, the office/outpatient consultation codes are updated to allow the provider to select the level of visit based on medical decision making (MDM) or time, when the latter is applicable.

The revised office/outpatient consultation E/M codes for CY 2023 are as follows (Note: portions of the revised descriptors are emphasized for easy reference):

• 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straight­forward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.)
• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.)
• 99245 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.)

Overtime code: A parenthetical note is added after 99245 instructing you to use prolonged services add-on code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)) for services lasting 70 minutes or longer.

You should check your individual payer policies as the policies are released since different payers may have different rules regarding prolonged services coding.

However, if you’re using the 2023 CPT^® guidelines and you’re billing an E/M visit solely based on time, you can assign +99417 only after 15 minutes have elapsed beyond the minimum time required for the highest-level primary service. In the cases of office/outpatient consultations, you cannot assign +99417 until 15 minutes have passed after the initial 55 minutes of the 99245 consultation — in other words, 70 minutes total. Additionally, the 15 minutes of +99417 may count regardless of whether the provider was in direct contact with the patient.

Descriptor change: When the calendar flips on Jan. 1, 2023, you should take note of the revision to +99417’s code descriptor. The new descriptor will read as follows:

• Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service)

Key code deletion: While present in the 2022 CPT^® code set, 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making ...) is deleted from the 2023 CPT^® code set. Instead, you’ll report 99242 for a consultation that involves straightforward MDM.

Understand How to Choose the Correct Consultation Code

How will consultation codes change in CY 2023? “As part of the 2023 revisions, this range of consultation codes can be documented through either time or MDM. History and exam, as with office visits, are no longer key components of consultations,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager at Eisner Advisory Group LLC in Iselin, New Jersey.

Going forward on Jan. 1, 2023, you’ll use either documented time or MDM to support your E/M consultation code choice. You should review your individual payer preferences, but if they don’t have specific additional requirements, you, along with provider documenters, can decide how to support your code choice for the encounter. Provider documenters are the providers who document and select the code.

What if you have a report that states the provider used a certain level of MDM, but the total time surpassed a higher level of MDM? “If the provider documents cumulative time along with the MDM and relevant history/physical examination, the coder can select the method that benefits the provider,” 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.

The same applies to provider documenters. The provider has the ultimate responsibility to document and select the code. “If the provider believes the encounter was especially lengthy, they may choose to document the time spent in various activities and select a code based on time,” Clark adds.

Example: A physician performs an E/M visit where the documentation supports moderate complexity (99244), but the total time for the visit is 55 minutes (99245). In this case, you can assign 99245 for the service.

Note: In next month’s issue, we’ll continue to examine the 2023 Office or Outpatient Consultation E/M coding guidelines, where you’ll learn how to code when a provider starts diagnostic testing during a consultation as well as knowing if your payer requires consult or other E/M codes for the visit.