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Maximizing Reimbursement with the 2023 CPT E/M Guidelines

By Leigh Poland RHIA,

June 22, 2023

When the 2023 Current Procedural Terminology (CPT) code set from the American Medical Association (AMA) took effect on January 1, 2023, there were modifications to the evaluation and management (E/M) codes among the 393 editorial changes. These changes include 223 new codes, 75 deletions, and 95 revisions to codes and guidelines in five code categories.

These new revisions build upon the 2021 revisions to the E/M codes for office/outpatient visit services. With those changes, the Centers for Medicare and Medicaid Services (CMS) allowed providers to document office visits based on medical decision-making (MDM) or total time and eliminated patient history and physical exam elements from the E/M coding process, as appropriate. The new modifications now extend to inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services, and prolonged services.

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The aim is to ease administrative burdens faced by physicians and care teams as well as streamline coding processes to be easier and more flexible. Accurate coding ensures that organizations have the appropriate data to make high-quality care more accessible to patients while also receiving timely and correct reimbursement for all services.

Leveraging Insights to Increase Revenue

The first quarter of the year is concluded, and we now have three months of valuable data about these updates from coding audits, provider audits, and E/M code assignments. The key findings are meaningful and welcome: the 2023 E/M guideline changes require physician documentation to be legible, timely, complete, precise, and clear now more than ever. Accurate and thorough documentation can impact the E/M level and thus have a substantial impact on revenue. In fact, when facilities, physicians, and organizations understand the application of the new E/M guidelines and encourage thorough documentation, they have the potential to increase reimbursement.

Providers from large universities and large physician groups to smaller practices are experiencing similar unexpected yet encouraging results across a wide range of specialties. Data analyzed between December 2022 and February 2023 reveals unique insights into how codes are impacting the bottom line, why providers are experiencing a revenue uptick, and how proper documentation can make it easier to gain higher levels of reimbursement. When the guidelines are applied properly, and the MDM results are interpreted correctly, there is significant payback.

Note bloat, where information is copied and pasted from patient charts, can lead to increased denials. It is worth the investment to meticulously update the notes with the proper specificity to document elements that support medical necessity. For example, take the time to precisely describe the results from procedures like an EKG, a CT scan, and lab tests because our data confirms it will make it easier to bill higher-intensity, more profitable E/M codes.

What do these discoveries mean for your organization? In short, it is more critical than ever to understand how coding impacts the bottom line to ensure organizations do not miss out on potential revenue reimbursement. In fact, following key best practices directly correlates to receiving both accurate and higher-level reimbursement.

AGS Health offers multiple solutions to support your team in optimizing the CPT guidelines and code updates. If you would like to learn more about optimizing E/M coding for higher reimbursements, we invite you to check out our recent webinar, “Are You Missing Reimbursements From Your E/M Coding?”

Leigh Poland

Leigh Poland RHIA, CCS

Author

Leigh has over 20 years of coding experience and has worked in the coding and education realm over the last 20 years. Her true passion is coding education making sure coders are equipped to do their job accurately and with excellence. Academically, Leigh has graduated from Louisiana Tech University with a Bachelor of Science. Leigh has had the opportunity to present many times in the past at the AHIMA, ACDIS, and AAPC National Conventions. She has been a guest speaker on AHIMA webinars and has written several articles that were published in the AHIMA Journal. Leigh has traveled the US and internationally providing coding education.

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