Question Is CMS using the AMAs 2023 Inpatient EM coding?

LauraNewYork

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On July 7, 2022, CMS published the 2023 Medicare Physician Fee Schedule Proposed Rule. In it they proposed "clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion, until CY 2024."

The AMA is indicating that the 2023 MDM grid (with a few changes) is to be used for both inpatient and outpatient.

I am not clear on which rule (CMS or AMA) to use for our specialists who see inpatients in 2023. Can anyone provide some guidance on this issue?
 

sls314

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On July 7, 2022, CMS published the 2023 Medicare Physician Fee Schedule Proposed Rule. In it they proposed "clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion, until CY 2024."

The AMA is indicating that the 2023 MDM grid (with a few changes) is to be used for both inpatient and outpatient.

I am not clear on which rule (CMS or AMA) to use for our specialists who see inpatients in 2023. Can anyone provide some guidance on this issue?

You're talking about 2 different things. The part you quoted from CMS is not in reference to selecting an E/M level for the visit.

It is in reference to determining who provided the substantive portion of a visit - the physician or the NPP. That determines whether a split-shared visit needs to be billed under the physician for 100% of the CMS fee schedule payment, or under the NPP for a reduced payment.
 

sls314

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Will the '95, '97 guidelines still be used for guidance to determine inpatient substantive portion in 2023?

No, the 95 and 97 guidelines have never applied to defining the substantive portion. That was used for E/M leveling.

Substantive portion is showing who did the majority of the work for the patient - the physician or the NPP. You can define "majority of the work" by showing who performed the history, who performed the exam, etc. Or you can use time - ex: the physician spent 31 minutes with the patient and the NPP spent 29.
 

sls314

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Here's an excerpt from the summary of the rule - you can see that the E/M Level section is following the AMA definition:


Evaluation and Management (E/M) Visits

As part of the ongoing updates to E/M visit codes and related coding guidelines that are intended to reduce administrative burden, the AMA CPT Editorial Panel approved revised coding and updated guidelines for Other E/M visits, effective January 1, 2023. Similar to the approach we finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, we finalized and adopted most of these AMA CPT changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023. This revised coding and documentation framework includes CPT code definition changes (revisions to the Other E/M code descriptors), including:

  • New descriptor times (where relevant).
  • Revised interpretive guidelines for levels of medical decision making.
  • Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services).
  • Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).
We finalized the proposal to maintain the current billing policies that apply to the E/Ms while we consider potential revisions that might be necessary in future rulemaking. We also finalized creation of Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in CY 2021 for payment of Office/Outpatient prolonged services. These services will be reported with three separate Medicare-specific G codes.

Split (or Shared) E/M Visits

For CY 2023, we finalized a year-long delay of the split (or shared) visits policy we established in rulemaking for 2022. This policy determines which professional should bill for a shared visit by defining the “substantive portion,” of the service as more than half of the total time. Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit is comprised of any of the following elements:

  • History.
  • Performing a physical exam.
  • Medical Decision Making.
  • Spending time (more than half of the total time spent by the practitioner who bills the visit).
As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion, until CY 2024.
 
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