The American Medical Association Current Procedural Terminology (CPT) Editorial Panel released the updated CPT Evaluation and Management (E/M) Office or Other Outpatient Code and Guideline Changes, which became active on January 1, 2021 (https://www.ama-assn.org/system/files/
2019-06/cpt-office-prolonged-svs-code-changes.pdf). Highlights of the new 2021 Guidelines compared to the 1995 and 1997 Guidelines included allowing performance and documentation of a medically appropriate history and exam rather than having to meet specific criteria, revising the way that time is counted (total time spent on that patient that calendar day rather than face-to-face time), and revising the medical decision-making guidelines. Ultimately, the number of new patient levels was reduced to 4 (99202-99205) while keeping 5 levels of established patient visits (99211-99215). This update was a major step towards reducing provider documentation burden and allowing practitioners to focus on that which was most important to patient care, while also recognizing patient complexity and management considerations in level selection rather than volume of documentation. A limitation of this update is that it was effective only for new and established office or other outpatient services. No other E/M codes were similarly updated. That is changing.

On January 1, 2023, a number of other E/M codes will be similarly updated to mimic that of the updated Office and Other Outpatient codes guidelines, including similar documentation requirements, medical decision-making guidelines, and updated time requirements. Updated codes which are of highest interest to urologists include Consultation codes (CPT codes 99242-99245) for insurers that recognize consultations, and Hospital E/M codes. In addition to these changes, hospital E/M codes will also be consolidated from 2 unique sets of codes (one for inpatient care services and another set for observation care services) to 1 set of codes that can be used for observation or inpatient care services. The results of these 2 changes will greatly improve ease of documentation and ease of coding for hospital services.

Table 1. Hospital Care E/M Codes (pre-2023): Description, Documentation, and Coding Requirements

For those who are not facile at hospital visit coding, currently coding is based upon patient status: Observation of Inpatient services. Observation codes include initial observation care (CPT codes 99218-99220), subsequent observation care (CPT codes 99224-99226), and discharge day services (CPT code 99217), along with same day admission/discharge from inpatient or observation care (99234-99236; Table 1). Inpatient care codes include initial hospital care (99221-99223), subsequent hospital care (99231-99234), and discharge day services (99238-99239), along with CPT 99234-99236 (Table 2). Consultants to patients in observation may use outpatient consultation codes (99241-99245), new patient codes (99201-99205), and established patient codes (99211-99215) depending on the patient’s insurance (if the insurer recognizes consultations or not), as observation care is considered an outpatient site of service, whereas consultants to inpatients would use hospital consultation services codes (99251-99255) or initial hospital care codes (99221-99223) depending on patient insurance. As ­documentation and time requirements are actually identical between initial observation care and initial hospital care, and also identical between subsequent observation care and subsequent inpatient care, combining the 2 sets into 1 code set made sense (Table 3). Ultimately, observation codes (99218-99220, 99224-99226, and 99217) were eliminated and merged into the current inpatient care codes.

Table 2. Observation Care E/M Codes (pre-2023): Description, Documentation, and Coding Requirements

As an example, the current description of CPT code 99211 is as follows:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor unit.

Table 3. Inpatient or Observation care E/M codes (starting January 1, 2023)

Note that for inpatient services, all 3 components (history, exam, and medical decision making) are required for the initial visit day while 2 of the 3 components are needed for subsequent care days. Time is a typical time, not a minimum time.

Starting January 1, 2023 the description of CPT code 99211 will be as follows (with the major changes italicized):

Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.

A few details to remember about this coding update: in the new guidelines, since history and examination are only that which is medically necessary, medical decision making or time can be used for code selection. As there is now only 1 set of codes that can be used for inpatient or observation care, the same CPT codes would be chosen no matter the patient status. When using time for code selection, it is no longer “typical” time that should be noted but a minimal time is required. Despite having only 1 set of codes, one must still report the patient status (observation care or inpatient) as that must be submitted with the bill, especially in the case of a status change such as a patient needs to be admitted as an inpatient after an observation stay. If billing based upon time, there will be an add-on code that will be able to be used for prolonged time; the details of this code and its use will likely be released in late 2022; as of not it appears that this code will be used for >90 minutes for initial inpatient or observation care, >65 minutes for subsequent inpatient or observation care, and >100 minutes for same-day admission/discharge from inpatient or observation care. Same-day admission and discharge from inpatient or observation care (CPT codes 99234-99235) are basically unchanged for their descriptor but have updated documentation requirements, medical decision-making guidelines, and minimum time requirements.