• 2023 Brings Important Coding, Medicare Payment Updates

    Hospital, Nursing Home E/M Visit Coding to See Big Changes

    Dec. 20, 2022, 3:20 p.m. News Staff — Two years ago, the AAFP was busy developing resources to help members prepare for major revisions to office visit evaluation and management coding and documentation guidelines scheduled to take effect Jan. 1, 2021. The changes, intended to reduce physicians’ administrative burden and allow them more time for direct patient care, followed extensive advocacy by the AAFP and other medical groups.

    hands with January 1 mask

    This year, the AAFP began educating members about similar changes coming in 2023 to coding for E/M services provided in hospitals, nursing homes and other settings (e.g., patients’ homes), beginning with a session at the 2022 Family Medicine Experience.  Members are encouraged to keep an eye out for additional information and resources to be released on this topic.

    Changes to E/M Codes and Guidance

    As of Jan. 1, code level selection for facility-based E/M services will largely mirror that now used for office/outpatient E/M services. The history and physical examination will no longer contribute to the level for these visits; rather, physicians will select codes for these services based on either the total time they spent caring for the patient on the date of the encounter or their level of medical decision-making. (The exceptions will be emergency department visits, which must be MDM-based because the codes do not have a time component, and hospital-discharge and nursing facility-discharge visits, which can only be coded based on time.)

    Furthermore, only a few adjustments are needed to repurpose the MDM table used to select office-based E/M codes for use in coding hospital and nursing home E/M services. They are

    • adding “1 stable acute illness” and “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care” to the low-level MDM elements in the problems addressed category;
    • adding decisions regarding “escalation of hospital-level of care” and “parenteral controlled substances” to the high-level MDM elements in the risk category; and
    • adding “multiple morbidities requiring intensive management” to the risk category, although this applies only to initial nursing facility visits.

    Story Highlights

    Other CPT changes that stand to affect how these services are reported include

    • hospital inpatient and observation codes have been collapsed into a single family of codes: 99221-99223 and 99231-99233;
    • the lowest level emergency department code (99281) has been redefined to describe visits that may not require the presence of a physician or other qualified health care professional;
    • the specific code for the nursing home annual exam has been deleted; this service will now be coded as a subsequent nursing home visit (99307-99310); and
    • the “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” and “Home Services” E/M visit families have merged into a single code family titled “Home or Residence Services.”

    For more details about the changes, members can review an FPM article published online ahead of print on Dec. 5; the article will appear in the January/February print journal issue.

    On a related note, CPT has revised its hospital E/M guidelines to allow more than one service to be reported when a patient is admitted to inpatient or observation status during a visit at another service site, such as a physician’s office. According to the guidelines, physicians should append modifier 25 to the initial service and report the hospital-based service, as well. CMS, however, is continuing its policy of allowing only a single service to be reported to Medicare in such instances. It is unclear at this time whether non-Medicare payers will follow CPT’s lead.

    Another CPT-related change involves how prolonged services — whether provided in an office or inpatient setting — should be reported. CPT has deleted the codes for reporting prolonged E/M services with direct patient contact in an office (99354-99355) or inpatient (99356-99357) setting. Physicians have been able to use code 99417, in conjunction with 99205 or 99215, to report prolonged services in the office setting since the 2021 changes were implemented; as of Jan. 1, that will be the only option for doing so. A new code, 99218, will be used to report prolonged hospital or nursing facility services.

    Although CPT guidance allows physicians to report 99417 or 99418, along with a primary E/M code for the highest level of service in the appropriate setting, when they surpass the minimum time of the highest level of service by 15 minutes, Medicare requires clinicians to surpass the maximum time of the highest E/M level by 15 minutes before reporting prolonged services codes. CMS has developed specific Healthcare Common Procedure Coding System codes, broken down by practice setting, for reporting such services.

    A second FPM article slated for the January/February issue but published early online shares more information about these additional coding updates. The article also outlines new and revised codes and related guidance for remote therapeutic monitoring, vaccine products and administration, and suture and staple removal.

    Medicare Payment Updates

    CMS has announced it will implement separate coding and payment for chronic pain management services beginning Jan. 1 and define the group of health care professionals eligible to provide this care to include nonphysician practitioners such as physician assistants and nurse practitioners. The agency has created new HCPCS codes to report chronic pain management and treatment that encompass holistic chronic pain care services, including assessment and monitoring; administration of a validated pain rating scale or tool; and development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, desired outcomes, and overall treatment management.

    CMS considerably expanded the list of services that can be provided via telehealth during the COVID-19 public health emergency, and a number of those will remain on either a temporary or permanent basis in 2023. Telehealth services that will continue to be available temporarily (that is, through the end of 2023 or 151 days after the PHE ends, whichever is later) include several emotional/behavioral assessment, psychological, and neuropsychological testing and evaluation services, as well as audio-only services. Some prolonged services and chronic care management telehealth services will continue permanently.

    Medicare Alternative Payment Program Changes

    Finally, although Medicare’s Quality Payment Program and the Medicare Shared Savings Program won’t radically change in 2023, family physicians may want to familiarize themselves with some upcoming modifications.

    In QPP’s Merit-based Incentive Payment System, for example, MIPS Value Pathways will be a new reporting option. Of 12 MVPs available for clinicians to report, two will focus on primary care: promoting wellness and optimizing chronic disease management.

    In addition, the 2023 MIPS performance threshold will remain at 75 points, with eligible clinicians receiving payment increases or reductions of up to 9% on their Medicare Part B claims. There is no exceptional performance threshold in 2023.

    Changes to the MSSP include the provision of Advance Investment Payments to new program entrants with no performance-based risk experience. The payments will consist of a one-time payment of $250,000 and eight quarterly payments based on the number of beneficiaries assigned to the accountable care organization. CMS will recoup the payments from any shared savings the ACO earns during its current agreement period.

    CMS also will allow ACOs inexperienced with performance-based risk to remain in the Basic track level A for all five years of the agreement period. The Enhanced track will be optional for all participants.