Complete Story


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:

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:


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

OOS members have access to complimentary reimbursement assistance.

Access the online help form >

Printer-Friendly Version