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The 2023 CPT code changes include 25 codes removed from the guidelines. These codes are published and owned by the American Medical Association (AMA) and should be applied by qualified healthcare professionals starting January 1, 2023.
The removed CPT codes include:
- Consultation codes 99241, 99251
- Nursing facility service 99318
- Domiciliary, rest home (e.g., boarding home), or custodial care services, 99324-99328, 99334-99337, 99339, 99340
- Home or resident services code 99343
- Prolonged services codes 99354-99357
- Hospital observation services codes 99217-99220, 99224-99226
Revisions to CPT Code Modifiers and Medical Procedure Codes
Concerning Initial and Subsequent Services
Revisions to the CPT Evaluation and Management section include additional information under initial and subsequent services which apply to hospital inpatient, observation care, and nursing facility codes. The new codes are used by qualified healthcare professionals responsible for E/M services.
The code changes state that the physicians may only bill one initial service during inpatient, observation, or nursing facility stays. Follow-up services are to be billed upon subsequent visits. When physicians cover for one another, the healthcare professional performing the initial service must bill for the initial service. Upon further treatment, physicians covering for their colleagues report the subsequent service. Essentially, qualified healthcare professionals in the same group who practice the same specialty should bill as though they are the same physician.
Inpatient and Observation Care Services
Following the deletion of observation codes 99217-99220 and 99224-99226, groups will use two sets of codes to report procedures or other services for inpatients and patients in observation. The codes 99234-99236 should be used when the patient is admitted and released on the same day. Physicians should report patients who stay longer than a calendar day using 99221-99223 for initial services, 99231-99233 for subsequent visits, and 99238-99239 for discharge.
CPT codes and guidelines dictate that advanced practice nurses and physician assistants working with qualified healthcare professionals are considered to work in the same medical specialty and subspecialty.
The AMA has also changed guidelines concerning the admittance of a patient from another service site. Under the new standard, physicians may report the medical procedures at the initial site separately when patients are admitted to a hospital as an inpatient or a subject under observation at another site of service. To indicate significant, separate service performed by a qualified healthcare professional on the same date, the physician may apply CPT Modifier 25.
When a patient transitions from observation or inpatient or vice versa, the status change doesn’t indicate a new stay. Please keep in mind that Medicare and Medicaid don’t conform with the AMA’s guidelines regarding dates of service and may propose a new rule.
Emergency Department Services
Emergency department visits are neither new nor established patients. Use medical decision-making to determine the level of service.
Code 99281 is defined as an emergency department visit for evaluating and managing a patient that may not require the presence of a qualified healthcare professional. Medical practices can’t bill 99281 for services performed by a hospital-employed nurse, and Medicare doesn’t allow incident-to-services in a hospital emergency department, nursing facility, or office.
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How To Select Level of Service Using the 2023 Code Changes
The AMA has expanded code selection for office and outpatient visits. The codes now impact E/M services that doctors once selected based on exam, history, and medical decision-making. The level of service can be determined primarily by medical decision-making for specific procedures and other services.
The three elements of decision-making include the number and complexity of problems addressed during the visit, the risk of complications, morbidity, or mortality of patient management, and the amount of data to be analyzed.
The code changes to the level of service impact:
- Nursing facility services
- Home or residence services
- Emergency department services (time is not a factor in an emergency department visit)
- Hospital inpatient and observation care services (physicians should use one set of codes for both)
Prolonged Care Code Changes
The face-to-face prolonged care codes 99354, 99355, 99356, and 99357 no longer apply. The AMA keeps non-face-to-face prolonged care codes 99358 and 99359 for when services are delivered on a date that doesn’t involve face-to-face interaction. You can’t double count the time spent, and medical groups can’t report many services on the same date.
The prolonged service codes 99358, 99359, 99415, and 99416 have been revised and are no longer payable by Medicare. The AMA plans to debut a new prolonged care code sometime soon. The placeholder code is 993X0 and should be used for additional 15-minute extensions with or without patient contact. The new code can be combined with hospital codes 99223, 99233, 99236, and 99225 for consultation and 99306 and 99310 for nursing facilities.
Physicians can only use prolonged service codes with the highest level code in the category. Medicare does not accept these CPT codes.
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