Emergency Department Services: Defining “New Problem with Additional Work Up” – 2021 E&M and Beyond

We find ourselves halfway through 2022 and already we’re looking forward to the end of the year to see what those 2023 documentation guideline changes will be. I am most excited to see what those changes will be as we expand 2021 documentation guidelines into other types and places of E&M services and personally, I…

2023 Revisions to the 2021 E&M Documentation Guidelines

Acute uncomplicated illness or injury requiring hospital inpatient or observation level care As 2021 documentation guidelines are moving into other types and places of service, it’s time to start taking a deep dive! I want to start by looking at some of the implementations that have changed. There were two major new adaptions in the…

The Role of the History and Examination in 2023 Evaluation and Management Services

  December 2, 2022 | By Jill Young, CPC, CEDC, CIMC While listening to the virtual AMA CPT/RBRVS Annual Symposium lecture by Gift Tee, BS, MPH, Director of the Division of Practitioner Services in the Hospital and Ambulatory Policy Group (HAPG) of CMS on the Update from Centers for Medicare and Medicaid Services (CMS), I…

A Long Time Coming: 2023 Changes to Inpatient Prolonged Services

  November 25, 2022 | By Grant Huang, CPMA, CPC It’s been two years since CMS collaborated with the AMA to revamp Evaluation & Management (E&M) coding guidelines, including a rework of prolonged services codes in the office/outpatient setting. This process culminated in a disagreement between the AMA’s CPT manual and CMS’ fee schedule final…