Clinical Plagiarism - Is Your Documentation Putting Your Practice at Risk?-Handout 2

Handout 2

Pdf Summary

The document outlines changes and guidelines pertaining to the Current Procedural Terminology (CPT) Evaluation and Management (E/M) services codes, effective January 1, 2023. These changes include revisions, deletions, and additions of various E/M codes across different healthcare service settings, such as hospital inpatient and observation care, emergency department, nursing facility, home or residence services, and consultations.

Key updates include:

1. <strong>Deletions</strong>: Several E/M codes, such as those for hospital observation services (99217-99220), certain consultation codes (99241, 99251), and various domiciliary and home services codes (99324-99343), have been removed.
   
2. <strong>Revisions</strong>: Existing codes for hospital inpatient and observation care, emergency department services, consultations, and nursing facility services have been revised to better reflect the levels of medical decision making (MDM) involved.

3. <strong>Additions</strong>: Introduction of new codes for prolonged services (993X0), which capture extended clinical time beyond standard evaluation service levels.

4. <strong>Guidelines</strong>: New instructions elaborate on selecting the level of service based on medical decision making or total time spent with the patient. Four types of MDM—straightforward, low, moderate, and high—are outlined to help healthcare providers determine the appropriate level of service to report.

5. <strong>Time-Based Services</strong>: Emphasis on time worked by physicians or other qualified healthcare professionals is detailed, clarifying its role in code selection, particularly when services involve prolonged interaction beyond established code standards.

These changes aim to enhance the specificity and applicability of E/M codes, aiding healthcare practitioners in accurately reporting and documenting the level of care provided. It is crucial for medical professionals to review these updates and integrate them into their coding practices to ensure compliance and proper billing.

Keywords

CPT

Evaluation and Management

E/M services

code revisions

code deletions

code additions

medical decision making

prolonged services

time-based services

healthcare compliance