E/M Changes for 2023 and How They Impact Ophthalmology
Diane E. Zucker, M.Ed., CCS-P
Most of you may have heard that there are changes in the E/M documentation and coding process for 2023 for the E/M codes (99202 through all the E/M codes) not the vision codes (92002-92014 codes). For the outpatient care codes with the 99201-99215 codes, where most of your care takes place, the changes are minor. For physicians who provide support in the inpatient settings, nursing homes or in other facilities, the process that was initiated in 2021 for documenting care on appropriate level of history and exam with medical decision making or total time of clinical activities for an identified date will be the process for all E/M care in 2023.
In thinking about CPT code level selection under the new criteria the specific history and exam you perform is based on your clinical judgement and can be performed, with your review, by support staff as of last year. The problem level documented is critical to identifying the level of acuity along with the testing you order, review with the treatment plan risks.
A Review of the Problems Addressed in Ophthalmology Care when Coding the E/M Codes
Let’s first review the problem levels and how ophthalmology issues may be identified. The following are the updated levels in 2023 with a few examples of how they may fit in your day to care patient care:
- Minimal problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281). So this may be a simple suture removal or education time with support staff without the physician providing in person care.
- Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. This could be a simple recheck of a pink eye or conjunctivitis that does not have a permanent impact on vision or eye health.
- Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). "Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant. This would be your chronic eyes conditions that you monitor such as macular degeneration, diabetic eye disease, glaucoma or stable cataracts where there is no progression in disease and no change in care plan.
- Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self- limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. This might be the scratched cornea or a contusion around the eye, a blepharitis, or an ingrown eyelash for which there is no risk of vision impairment or long term concern. This might also be a foreign body of the eye.
- Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting would be rare in ophthalmology but some trauma cases may meet this level of acuity or an acute vision loss of eye origin, not neurologic, where you, the ophthalmologist was the primary physician involved in care.
- Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition. This might be the cellulitis of the eye area or shingles with ocular involvement that is resolving in nature.
- Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects. This would be any of the chronic eye conditions (macular degeneration, diabetic retinopathy, cataract progression, and glaucoma are the most common. The condition would be in poor control or not at goal, progressing in status with vision loss or functional issues.
- Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment would also be rare in ophthalmology but could be an eye tumor, sudden loss of vision or other condition that had a risk of vision loss but was not a clear diagnoses at assessment.
- Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system. The best example of this would be initial assessment of shingles of the ocular region or herpes of the eye with the identified additional symptoms.
- Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example of this level of acuity would be the eye trauma that could result in either loss of the eye or major loss in vision and function. This could also be an acute retinal detachment.
- Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care. The examples of this level of acuity would be the chronic condition that required immediate intervention (surgery) that within the narrative of the note identified that without this level of intervention there would be vision loss.
- Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity. This also would be that condition that without immediate treatment could result in major vision loss.
In documenting the nature of the problem it is critical to identify the nature of the condition and the timing needs for treatment and what the risks and benefits of the treatment (procedure) would be with the risk if the procedure is not performed as well as the risk benefit when performed.
Counting the Data you use to Determine a Care Plan
Much of the data used in Ophthalmology is part of the testing that you perform with patients and interpret separately as part of the care you provide. This would include the imaging and scans, tonometry, corneal topography, and other procedures which have a specific interpretation report. These tests do not count for data in the updated E/M guidelines but would support the acuity of the problem identified and risk for management/treatment.
Data that would count might include review of medical records from others – such as a primary care physician or endocrinologist in a diabetic patient; an ER report or a review of testing in a shared medical record such as lab work pertinent to your eye care. Services provided by an Optometrists or a Visual Rehabilitation Therapist would be documents that would count as data.
Identifying the Risk for Management and Treatment for Eye Conditions
The last component of the medical decision making deals the risk of complications and/or mortality of patient management. This includes prescription medication management, including eye drops, decisions regarding minor surgery, major surgery with and without other patient risk factors, social determinants of health.
The components related to risk include:
- Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. This would include significant vision loss or vision loss when combined with a secondary sensory loss, hard of hearing or deafness.
- Social determinants of health: Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity. These would be coded when there is a concern they could impact care, recovery and function – a patient living alone (Z60.2) may require support post eye procedure for drops as well as overall self -care.
- Surgery (minor or major, elective, emergency, procedure or patient risk) should reflect in the documentation their status and the impact on overall health, well -being and vision.
- Surgery—minor or major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.
- Surgery—Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
- Surgery—Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.
These changes at first glance may sense overwhelming but after review they are based on common sense and good medical practice. The important things to document in each and every note, no matter the location, is the status of the conditions you are treating and the secondary issues that may impact this plan. Additional reflection in your narrative for the assessment and plan would be the nature of the treatment plan with the risks and benefits and a review of the best case scenario with treatment and what may happen without treatment.
For physicians who provide consultation services (99242-99245 and 99252-99255) or inpatient work (99221-99233) one should review the 2023 AMA CPT Code text for a review of the updated rules in code use. This new process for all locations of care mean that you can focused on the patient care needs and not the bullets of exam or history for the documentation process when using the E/M codes.
Need More Information?
If you are also an OSMA 2023 member, you and your staff can access the following recorded webinars at no charge! Visit OSMA.org/ondemand
- Getting Ready for 2023 E/M Changes
- Documentation and Medical Decision Making
OOS members have access to complimentary reimbursement assistance.