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Urgent Care E/M

1. I am an ED physician, but I also work in an Urgent Care Center; do I need to follow the new CPT E/M guidelines for 2023?

Physicians/QHPs that provide care in an Urgent Care Center or Fast Track report their services with the Office or Other Outpatient E/M codes 99202-99215.

AMA and CMS approved new CPT E/M guidelines for the Office or Other Outpatient E/M codes 99202-99215, originally effective January 2021 and updated for January 2023.

2. How do the new Office or Other Outpatient E/M codes 99202-99215 guidelines differ from the 1995 CMS E/M guidelines?

The differences between the 2021/2023 CPT E/M Guidelines for the office visit codes and 1995 CMS E/M guidelines include:

  • They eliminate history and physical exam as elements for code selection.
    • The revised code descriptors state providers should perform a “medically appropriate history and/or examination.” However, these elements are not used to determine the appropriate code level.
  • Allowing physicians/QHPs to choose E/M codes based on Medical Decision Making or Total Time.
  • Revisions to the rules for using Time to assign an E/M code.
  • Modifications to the criteria for determining Medical Decision Making (MDM).

3. Am I no longer required to document a history or exam?

When reporting the Office or Other Outpatient E/M codes 99202-99215, the documentation should include a medically appropriate history and/or physical examination.

The nature and extent of the history and/or physical examination are determined by the treating physician/QHP. But the extent of history and physical exam documented is not used to assign the level of service when reporting the Office or Other Outpatient E/M codes 99202-99215.

4. What are the modifications to the criteria for determining Medical Decision Making?

  • There are minor changes to the three current MDM sub-components, but there have been extensive edits to the process of “scoring” MDM elements for code selection.
  • The current CMS Table of Risk and Contractor audit tools were used as a basis for designing the revised required elements for MDM.
  • Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
  • Defined important terms, such as “Independent historian,” “other appropriate source,” etc.

5. How is MDM used to assign Office or Other Outpatient E/M codes 99202-99215?

Three elements define medical decision making in the office and other outpatient services code set:

  • The number and complexity of problem(s) that are addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed.
  • The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit.

When assigning an E/M by MDM, the documentation must satisfy the requirement of at least two columns to report a level of service.

E/M Code

Level of MDM

Number and Complexity of Problems

Amount and/or Complexity of Data Reviewed

Risk of Complications and/or Morbidity or Mortality

99211

Evaluation of an established patient that may not require the presence of a physician/QHP.

99202 / 99212

Straightforward

Minimal

Minimal or none

Minimal risk

99203 / 99213

Low

Low

Limited

Low risk

99204 / 99214

Moderate

Moderate

Moderate

Moderate risk

99205 / 99215

High

High

Extensive

High risk

6. How are the Number and Complexity of Problem(s) Addressed measured?

Number and Complexity of Problems Addressed

Minimal

·         1 self-limited or minor problem.

Low

·         2 or more self-limited or minor problems

·         1 stable chronic illness

·         1 acute, uncomplicated illness or injury

·         1 stable, acute illness

·         1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care

Moderate

·         1 or more chronic illnesses with exacerbation, progression, or side effects of treatment.

·         2 or more stable chronic illnesses.

·         1 undiagnosed new problem with uncertain prognosis.

·         1 acute illness with systemic symptoms.

·         1 acute complicated injury

High

·         1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment.

·         1 acute or chronic illness or injury that poses a threat to life or bodily function

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Number and Complexity of Problem(s) Addressed.  

7. Amount and/or Complexity of Data Reviewed measured?

Amount and/or Complexity of Data to be Reviewed and Analyzed

Limited

Satisfy at least one category.

Category 1: Tests and documents

·         At least 2 from the following:

•        Review of prior external note(s) from each unique source; (each note counts as 1)

•        Review of the result(s) of each unique test; (each test counts as 1)

•        Ordering of each unique test (each test counts as 1)

 

Category 2: Assessment requiring an independent historian(s)

Moderate

Satisfy at least one category.

Category 1: Tests, documents, or independent historian(s)

·         At least 3 from the following:

•       Review of prior external note(s) from each unique source; (each note counts as 1)

•       Review of the result(s) of each unique test; (each test counts as 1)

•       Ordering of each unique test (each test counts as 1)

•        Assessment requiring an independent historian(s)

 

Category 2: Independent interpretation of tests

 

Category 3: Discussion of management or test interpretation

Extensive

Satisfy at least two categories.

Category 1: Tests, documents, or independent historian(s)

·         At least 3 from the following:

•        Review of prior external note(s) from each unique source; (each note counts as 1)

•        Review of the result(s) of each unique test; (each test counts as 1)

•        Ordering of each unique test (each test counts as 1)

•        Assessment requiring an independent historian(s)

 

Category 2: Independent interpretation of tests

 

Category 3: Discussion of management or test interpretation

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Amount and/or Complexity of Data Reviewed.

8. How is the Risk of Complications and/or Morbidity or Mortality measured?

Risk of Complications and/or Morbidity or Mortality of Patient Management

Minimal risk of morbidity from additional diagnostic testing or treatment

There are currently no published examples of what qualifies as minimal risk.

Low risk of morbidity from additional diagnostic testing or treatment

There are currently no published examples of what qualifies as low risk.

Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

·         Prescription drug management

·         Decision regarding minor surgery with identified patient or procedure risk factors

·         Decision regarding elective major surgery without identified patient or procedure risk factors.

·         Diagnosis or treatment significantly limited by social determinants of health

High risk of morbidity from additional diagnostic testing or treatment

Examples only:

·         Drug therapy requiring intensive monitoring for toxicity

·         Decision regarding elective major surgery with identified patient or procedure risk factors

·         Decision regarding emergency major surgery

·         Decision regarding hospitalization or escalation of hospital-level of care

·         Decision not to resuscitate or to de-escalate care because of poor prognosis

·         Parenteral controlled substances

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Risk of Complications and/or Morbidity or Mortality.

9. How are the rules for coding based on time revised?

As of 2023:

  • Physicians/QHPs must document their total time and satisfy the times specified in the code descriptors to report the E/M code.
  • Time alone may be used to select the appropriate code level for the office E/M services codes regardless of counseling and/or coordination of care dominating the service.
  • Time included is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician on the day of the encounter (includes time in activities that require the physician and does not include time in activities customarily performed by clinical staff).

Calculating the physician’s professional time includes the following activities when performed:

  • preparing to see the patient (e.g., review of tests)
  • obtaining and/or reviewing separately obtained history
  • performing a medically appropriate examination and/or evaluation
  • counseling and educating the patient/family/caregiver.
  • ordering medications, tests, or procedures
  • referring and communicating with other health care professionals (when not separately reported)
  • documenting clinical information in the electronic or other health record
  • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
  • care coordination (not separately reported)

Time spent performing separately billed services is not counted toward the time used to select the E/M code.

10. How much time is required for each E/M code?

New Patient:

  • 99201             Deleted as of 2021.
  • 99202             15 minutes
  • 99203             30 minutes
  • 99204             45 minutes
  • 99205             60 minutes

A new patient has not received any professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

Established Patient:

  • 99211 Nurse visit, may not require the presence of a physician/QHP.
  • 99212             10 minutes
  • 99213             20 minutes
  • 99214             30 minutes
  • 99215             40 minutes

An established patient has received any professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

11. What if my encounter exceeds the time allotted for 99201 or 99215?

Prolonged services can be reported when the physician’s total time during an office E/M service exceeds the maximum time associated with 99205 or 99215.

12. What are the codes for prolonged services, and how are they assigned?

For non-Medicare patients, Code 99417 (Prolonged office/outpatient E/M services with or without direct patient contact) is only used when time alone is the basis for selecting the E/M code and only after the total time of the highest-level service (i.e., 99205 or 99215) has been exceeded.

New Patient

  • 75-89 minutes 99205 X 1 and 99417 X 1
  • 90-104 minutes 99205 X 1 and 99417 X 2
  • 105 or more             99205 X 1 and 99417 X 3 or more for each additional 15 minutes.

Established Patient

  • 55-69 minutes 99215 X 1 and 99417 X 1
  • 70-84 minutes 99215 X 1 and 99417 X 2
  • 85 or more             99215 X 1 and 99417 X 3 or more for each additional 15

For Medicare patients, CMS policy instructs providers not to report prolonged office/outpatient E/M visit time using CPT code 99417.  CMS instructions are to report G2212 when prolonged service has been provided.

  • G2212 - (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact)

CMS provides the following table with reporting examples:

New Patient

  • 89-103 minutes 99205 x 1 and G2212 x 1
  • 104-118 minutes 99205 x 1 and G2212 x 2
  • 119 or more 99205 X 1 and G2212 X 3 or more for each additional 15 minutes.

Established Patient

  • 69-83 minutes 99215 x 1 and G2212 x 1
  • 84- 98 minutes 99215 x 1 and G2212 x 2
  • 99 or more             99215 x 1 and G2212 x 3 or more for each additional 15 minutes.

13. Do these revisions to the E/M guidelines also apply to the Emergency Department codes 99281 – 99285?

On July 1, 2022, the AMA released additional revisions to the rest of the E/M code sections, including the ED E/M codes.  The 2022 revisions will provide continuity across all the E/M sections.

The revised E/M codes, descriptions, and guidelines will apply to all E/M codes on January 1st, 2023.

See the 2023 E/M FAQ for more information.

14. Do these guidelines apply to the observation E/M codes also?

Yes, observation services will now use the MDM guidelines detailed above, or observation E/M codes can be assigned based on the physician’s total time on the encounter date.

However, the  Initial Observation Care codes 99218, 99219, and 99220, Subsequent Observation Care codes 99224, 99225, 99226, and Observation Discharge code 99217 have all been deleted for 2023. 

The inpatient E/M codes 99221-99223, and 99231-99239, have been revised to Hospital Inpatient and Observation Care Services.

See the Physician Observation FAQ for more information.

15. Where can I find the complete set of guidelines?

They can be found in the Evaluation and Management (E/M) Services Guidelines section of the 2023 CPT Manual. They can also be downloaded from the AMA website with this link https://www.ama-assn.org/system/files/2023-e-mdescriptors-guidelines.pdf

Last Updated January 2023

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

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For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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