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 was struck by something he said about the revisions to the coding and documentation framework for Evaluation and Management (E&M) Services for the 2023 CPT code descriptors.
His presentation indicated the revised coding and documentation framework for the 2023 revisions to E&M services includes the “elimination of history and exam to determine code level” that was introduced with updates to Office and Other Outpatient Services changes for Evaluation and Management Services from 2021. Mr. Tee’s presentation slides further showed a parenthetical note after the above-quoted text, that “instead there would be a requirement for a medically appropriate history and exam”. I was stuck on the two words “elimination” and “requirement”. It seemed these two were incongruous in that same sentence. It was also language I didn’t remember seeing before from either CMS or CPT.
I looked in the 2021 and 2023 CPT manuals and did not see it. I then revisited Medicare’s Physician Fee Schedule (PFS) Final rule for 2021 published in the Federal Register on December 28, 2020. It states “Under this new CPT coding framework, history and exam will no longer be used to select the level of code for Office & Other Outpatient E/M visits. Instead, an Office & Other Outpatient E/M visit will include a medically appropriate history and exam, when performed. The clinically outdated system for number of body systems/areas reviewed and examined under history and exam will no longer apply, and the history and exam components will only be performed when, and to the extent, reasonable and necessary, and clinically appropriate.” It appears that CMS has made a significant change to how and when the History and Exam elements are to be performed and documented in 2023 for all E&M services.
The language for both the 2021 and 2023 CPT rules indicated that the History and Exam no longer play a role in the calculation of the level of service. This is clear. Gone are the bullet points for data collection and the counting of them. But what does Medically Appropriate or Clinically Appropriate mean? I have, to date, found nothing to help understand how to satisfy this new “requirement” for the history and exam element for 2023. The previously published language from the 2021 Final Rule for Office & Other Outpatient and E/M services has apparently been replaced. Gone is the ability of the provider to determine when and to what extent the history and exam element needs to be performed. Now performance of these two elements has a “required” component. A definition or clarification beyond what we currently have is really necessary to help educators and auditors to do their jobs under these new rules. Hopefully, it will be forthcoming so we can all be ready to help providers and others be ready for the January 1, 2023 change.
Your next steps:
- Schedule a consultation for 2023 audit planning and a provider documentation review.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
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