The Center for Medicaid and Medicare Services (CMS) has finalized the 2023 Medicare physician fee schedule. CMS worked closely with the American Medical Association (AMA) and will generally adopt the new coding, prefatory language, and interpretive guidance framework that has been issued by the AMA’s CPT Editorial Panel for inpatient, observation, and emergency room visits that is effective as of January 1, 2023. Under this new CPT coding framework, history and exam will no longer be used to select the level of code for these services. However, a medically appropriate history and exam, when performed, should continue to be documented. These changes will align with the changes CMS made to the outpatient E/M codes effective January 2021. Therefore, the leveling of outpatient and inpatient services will be the same, which should be a welcome change for all providers. Further details of some of the more significant changes include:
- A grace period has been implemented allowing shared visits to be billed under the provider who performed the substantive portion of the E/M visit using whoever performed over 50% of the visit or who performed the medical decision making in its entirety. In 2024, time will be the only measure of "substantive."
- For inpatient and/or observation care, selection of the code level to report will be based on either the level of medical decision-making (MDM) or the total time personally spent by the reporting practitioner on the day of the visit (including face-to-face and non-face-to-face time). In addition, the codes for inpatient and observation have been combined into one code set.
- The time threshold for the inpatient and observation codes has changed.
- For emergency room care, selection of the code level to report will be based solely on the level of MDM, since there is no time associated with the emergency room codes.
- The lowest level of emergency room visit, CPT code 99281, does not require physician or advanced practice provider presence. The levels of MDM for emergency room visits have also changed.
- The MDM grid is updated with additional details for low and high MDM. Number and Complexity of Problems Addressed at the Encounter for low include: one stable chronic illness or one acute, uncomplicated illness or injury requiring hospital or observation level of care. For high risk, escalation of hospital level of care and parenteral controlled substances are now included.
- Level 1 for inpatient and outpatient consultations has been deleted and the times associated with levels 2–5 have changed.
- CMS chose not to adopt the changes the AMA made to the prolonged services codes and instead created their own code set. CMS differs from the AMA in the requirements to bill for prolonged services as CMS requires the total time described in the CPT code to be met, whereas the AMA requires the midpoint of time to be met. Yale Medicine (YM) aligns with the CMS rules.
The YM Medical Billing Compliance Department in collaboration with the Coding and Billing Department are working on educational tools and materials describing the changes for faculty and staff. Any questions regarding the final rule can be directed to the Compliance Department at judy.harris@yale.edu.