E/M Coding Update and the Impact on Time for Profee Coding

by | Feb 15, 2023

The intention of the January 1, 2023 E/M coding guideline changes were to make documentation simpler for physicians. 

“Our No. 1 job was to make it simple, practical and clinically relevant—you call that administrative simplification. Our No. 2 goal was to decrease the need for audits or to fight fear. No. 3 was to decrease the unnecessary documentation that was related to coding and not to clinical care and get rid of the junk.”

Peter Hollmann, MD, geriatrician and chief medical officer of the Brown Medicine faculty medical group and former chair of the CPT Editorial Panel

The new E/M coding guidelines in practice

We agree that these guidelines are a step in the right direction for physicians since documentation burdens have plagued providers for years. But it’s important to focus on how their actual patient time will play a role in reimbursement, and which patient encounters could be most impacted by the new guidelines. 

With the new 2023 Inpatient and Observation Evaluation and Management professional fee coding guideline, professional fee coders can either code based on medical decision making as shown in the grid in Figure 1 below or based on the total time documented for patient visit. Medical decision making is based on multiple points, and even if points show that a patient is bad off, the documentation might not promote a level 3 E/M. If medical decision making doesn’t support a level 3, the provider would need to specifically document how long they spent with the patient in order to qualify for reimbursement at level 3. The coder looks at both situations to determine which is going to meet the higher level. 

Why is the E/M coding shift so important?

This shift is significant because there was no time requirement before, it was only for critical care or discharge services. Providers who don’t document their time might not present an issue in a specialty like cardiology for example because patients could present quite sick. 

But other specialties that spend a lot of time with patients but don’t meet medical decision making for level 3 should take note. For example, hospitalists, behavioral health specialists and pulmonary specialists spend a lot of time with patients.  

When extrapolated across 1,000s of charts per month, providers should be cautious of the reimbursement impact. Before 2023 it was easier to meet criteria for a level 3 because physicians were used to documenting history, physical, exam and medical decision making. 

I predict it will take some time to get used to this change. It’s important for HIM directors, coding managers and outpatient CDI teams to remind physicians to document their time. Otherwise, organizations could see a loss in revenue in the year ahead. 

Want to dig deeper into IP E/M updates? Download two additional resources:

2023 Inpatient or Observation Evaluation and Management Time Tables >>

Example of Time versus Medical Decision Making (MDM)

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