The process by which office and other outpatient evaluation and management (E&M) levels (CPT® 99202 – 99215) are selected was changed by the AMA CPT® Editorial Panel effective January 1, 20211 . This was a welcome change as it resulted in the removal of barriers that made it difficult for some specialists to reach higher level office and other outpatient E&M levels. Effective January 1, 20232, under the guidance of the AMA CPT Editorial Panel, these same changes will also be applied to the method used to select the level of these E&M services:

  • Hospital Inpatient and Observation Care
  • Consultation
  • Emergency Department
  • Nursing Facility
  • Home or Residence

With this change, the levels of office or other outpatient, hospital inpatient and observation care, consultation, emergency department, nursing facility, and home or residence E&M services will be selected based on medical decision making only or total time only.

Medical Decision Making

Effective January 1, 20232, when using medical decision making to determine the E&M level for any of these E&M types, the four medical decision making levels are:

  • Straightforward Medical Decision Making
  • Low Medical Decision Making
  • Moderate Medical Decision Making
  • High Medical Decision Making

When choosing the E&M level based on medical decision making, three elements of medical decision making are considered:

  • Number and Complexity of Problems Addressed
  • Amount and/or Complexity of Data to be Reviewed and Analyzed
  • Risk of Complications and/or Morbidity or Mortality of Patient Management

Effective January 1, 20232, each of these E&M types will have its own thresholds of those three elements. When reviewing an encounter, if what was medically necessary, performed, and documented meets the thresholds of two of a level’s three elements, that E&M level may be selected. AMA CPT shares the details of each of those thresholds here https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

Total Time

Effective January 1, 20232, when using time to determine the office or other outpatient, hospital inpatient and observation care, consultation, emergency department, nursing facility, and home or residence E&M level the total time spent by the provider performing the evaluation and management on the calendar date of the encounter is considered. Each of the CPT code descriptors for the E&M types listed in this article includes a time value in minutes.



Reference




1 American Medical Association CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes.  https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf


2 https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf




    

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