Medicare Documentation Guidelines to See the Most Significant Change since 1995
The ED E/M CPT 9928X code sets and the commensurate Medicare Documentation Guidelines (DGs) came into being in 1994-1995 after a long period of analysis, debate and testing. Some may recall that ED clinicians had 6+ months to use the new 1995 DGs in a “testing mode” in 1994 before they became finalized. Also, the concept of “payor specific” E/M coding standards was born as the 1995 Medicare DGs required certain “counting of elements” that were not per se required in CPT, e.g., 4 elements of the HPI for a Medicare CPT 99285. All of that history will be just that on 1/1/23 when the CPT and CMS standards for ED E/M documentation and coding will be one standard, if as we expect, CPT publishes their standards sometime this summer (stakeholders are advocating for accelerated release of the new 2023 standards given the degree of change in the standards and timeline needed for clinician and coder education.)
While the precise standards are not presently known, it is widely believed that we know the outline of the major changes (see the chart below). These ED E/M changes will align with the changes made in the 2021 Office or Other Outpatient (OP) E/M codes. The 2021 E/M office and OP criteria changed from requiring three key components: 1) history, 2) physician examination, and 3) medical decision-making (MDM), to standards requiring either MDM or time. Since time has not been a CPT requirement in the ED E/M codes set in the past, we believe that time will not be required for the CPT 9928X codes sets going forward.
We currently expect that, as required by the Office and OP E/M codes, the emergency clinicians will be required to perform and document a medically appropriate History and/or Physical Examination. It is expected that MDM may become paramount under the new 2023 standards. We are currently engaged in analyzing the possible impacts of the new 2023 standards on client’s current E/M coding distributions and will be communicating with clients throughout the year regarding the new 2023 E/M standards.
Have question or want to see more coding-related updates and information from Zotec Partners? Reach out to Ed Gaines at egaines@zotecpartners.com.
