Updated E/M manual adds plain-English guidance for critical care, split/shared, prolonged visits

by: Julia Kyles, CPC Aug 30, 2023

Better late than never: CMS released a new version of its Evaluation and Management Services Guide on Aug. 29. CMS withdrew the 2022 version of the manual on Feb 7. The updated online manual synchs up with guidelines and rules for E/M visits that went into effect Jan. 1, 2023.

The update makes it clear that you should use the codes and descriptors from the 2023 CPT Manual, except for prolonged service codes 99417 and 99418. It includes a plain-English version of guidance in CMS 100-04, Change Request 13064 (Part B News blog, 2/9/23).

The Medicare manual also gives you information on E/M topics such as how to document and report critical care, chronic pain management services (G3002-G3003) and teaching physician services. However, you’ll need your CPT manual for basic coding information including code descriptors, time-based coding and split/shared visits under CPT guidelines.

Here are three highlights from the new guide:

A clear chief complaint is still essential. “Another interesting definition that was left in was 'chief complaint.’ This has been removed from the E/M CPT guidelines,” observes Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, CCDS-O, director of HIM/coding for HCPro. “This clarifies that it is still required for CMS even though the AMA removed the definition from the E/M Services guidelines in 2023,” McCall says.
CMS sets a different time for critical care. According to the guide, you can’t report critical care add-on code 99292 until the provider spends at least 104 minutes with the patient, McCall notes. “This differs from the table in CPT that allows +99292 to be reported once 75 minutes has been met,” she says.
A history or physical exam is a must. According to the 2023 CPT manual, “E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed,” which allows providers to decide whether they’ll perform and document those services. However, CMS appears to stick with the codes’ descriptors, which include the following language: “...requires a medically appropriate history and/or examination.” However, the treating provider can still decide the extent of the history or exam. According to the guide, when a provider performs level-based E/M visits, “they include a medically appropriate history or physical examination. The treating physician or other qualified health care professional reporting the service determine the nature and extent of the history or physical examination.”

You should also note two areas that still need some clarification.

Threshold time for prolonged services. You can count time on days before, after or before and after a face-to-face visit toward prolonged time for a few types of E/M visits. “They don’t really say if they require that the time spent on the date of the encounter must meet the AMA code description, but one assumes so,” McCall says. For example, if the provider performs an initial nursing facility visit you can count the time one day before the visit, the day of the visit and three days after the visit toward the 95-minute threshold for prolonged service code G0317. But CMS doesn’t say whether the provider must meet or exceed the 45-minute threshold for the nursing facility code (99306) on the day of the face-to-face visit.
Documenting time-based services. The level of detail CMS expects for time-based visits remains an open question. According to CMS 100-04, Change Request 13064 “reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.” The guide does not give more information on how to meet the reviewers’ objective standards.

Finally, practices should note that according to the split/shared visit section, practices can determine the substantive portion based on a component of the visit (history, exam or medical decision-making) in 2022 and 2023. But CMS has already announced that it plans to let that exception run until 2025 in the proposed 2024 Medicare physician fee schedule (Part B News blog, 7/13/23).

Blog Tags: CMS, E/M services

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