by Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI
Welcome to Compliance Corner, a department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This resource aims to help you navigate recent changes to Current Procedural Terminology® (CPT®) Evaluation and Management (E/M) guidelines for office visits, which became effective January 1, 2021. Written by the American Medical Association (AMA), these guidelines contain new methodology and new definitions, both of which affect the way you as providers document the account of the patient visit.
It is that time of year when we anxiously await code changes and updates. Along with potential code changes there are often policy and/or guideline changes and updates also. In this article, we will examine some of the updates for 2023 and look at a few updates to the 2021 E/M documentation guidelines.
New diagnosis codes for the following year go into effect October 1 of the current year. There were no additions, deletions, or code revisions for any of the codes found in Chapter 12 Diseases of the Skin and Subcutaneous Tissue. These are the codes that begin with the letter L and are most often used within Dermatology practices.
The 2023 edition of ICD10-CM did provide some updates to the Official Coding Guidelines. The following outlines some of the important updates to the general guidelines.
First, a reminder about the importance of these Official Guidelines taken directly from the guidelines.
“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”
This is a great reminder of the importance of these guidelines. Auditors use this set of guidelines when reviewing documentation for coding accuracy.
Updates to the Official Coding Guidelines
1.A.19—Code Assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.
1.B.14—Documentation by Clinicians Other than the Patient’s Provider
The body mass index (BMI), coma scale, The National Institutes of Health Stroke Scale/Score (NIHSS), blood alcohol level codes, codes for social determinants of health, and under-immunization status should only be reported as secondary diagnoses.
(Added under-immunization to the list of exceptions) This statement works directly with the 2021 guidelines for selecting a level of service for an encounter. The problems addressed must be clearly documented by the provider. An auditor or a coder may not assume a condition based on clinical criteria that has been documented, it must be documented by the provider.
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. Discontinuing the use of a prescribed medication on the patient’s own initiative (not directed by the patient’s provider) is also classified as an underdosing. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”). Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.
Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.
It is so important to capture the correct clinical scenario for that patient. If a patient is not improving or is at a higher risk due to not following medication instructions, that should be captured in the medical record and on the claim that is being reported.
These are the most general and important updates that will affect most providers. Please refer to Appendix B of your 2023 ICD10-CM manual for all other updates.
The new AMA CPT codes for 2023 will go into effect January 1, 2023. It looks like there are no major updates to the Integumentary section. The BIG update for 2023 is once again in the E/M Section. The 1995 and 1997 Documentation Guidelines will have officially gone away and are being replaced with wording very similar to the 2021 Guidelines for Office and Other Outpatient Services.
As you know, the 2021 guidelines allow providers to select a level of services based on either the documented medical decision-making or based on the documented total time for that date of service. That rule will now extend to the other types of services E/M being provided. The exception would be any type of service where the code was not leveled, such as critical care or preventive services. To accommodate the conditions that may warrant an emergency room visit, observation admission, or inpatient admission, the AMA did update its tables for medical decision-making. These updates will be used in the office setting as well. The E/M section will have one set of guidelines and definitions.
Two New Definitions to “Problems Addressed” in the Medical Decision-Making Table
The following two definitions appear under the category for “Low Complexity Problems Addressed”:
• Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
• Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
This update is a reminder that it is the responsibility of the provider to indicate the status of the condition at each encounter.
Two New Definitions to “Risk” in the Medical Decision-Making Table
The following two definitions appear under the category “Moderate Complexity Risk”:
• Decision regarding hospitalization or escalation of hospital-level care
• Parenteral controlled substance
These two may not affect all providers who are reading this article. Many providers reading may not be seeing patients in the hospital.
The following is a brief overview of the changes in the E/M section that will take place January 1, 2023:
• Updates throughout the E/M guidelines to support all categories
• Minor changes to the Medical Decision-making (MDM) table
• All E/M categories will be selected based on MDM or time, except emergency department selected based on MDM only
• Deletion of observation codes—directed to inpatient and observation category
• Deletion of domiciliary, rest home (e.g., boarding home), or custodial care services–directed to home services
• Prolonged services updated to include new times associated with hospital inpatient services and other outpatient services
If any providers are seeing patients in the hospital setting, ER, or other locations where the level is currently being reported based on the documented history and exam and medical decision making, it is recommended to begin looking at the upcoming guideline and code changes now. They can be downloaded from the following link. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
AMA 2023 E/M Guidelines
Also keep in mind that in the beginning of November, CMS will release their Final Rule for 2023. They will make a statement concerning split/shared services in the facility and make their final comments concerning the new 2023 Guidelines from the AMA.
It is time to get ready and get prepared. You do not want to be late to the party!
If you have questions or suggestions for topics to cover in upcoming issues, please let us know at coding@ dermpa.org.
Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI has been working in the field of medical cohas been working in the field of medical coding and auditing for over 30 years. She has been a Certified Professional Coder (CPC) since 1994, attained her Certified Outpatient Coder (COC) for facility-based coding in 2005, and is a Certified Professional Medical Auditor specializing in Evaluation and Management (E/M) Coding. She has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She has served on the American Academy of Professional Coders (AAPC) National Advisory Board and is past president of AAPC’s Richmond and Charlottesville, Virginia, local chapters. Kipreos is president of Practice Integrity, LLC, where she manages a national client list and provides compliance monitoring for provider documentation. She currently resides in San Diego, California.
Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.