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See How Coding for 2 E/M Visits on 1 Day Dramatically Changed

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See How Coding for 2 E/M Visits on 1 Day Dramatically Changed

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Evaluation and management codes

It’s a question that has confounded coders and practice managers for years: What do you do if you see a patient in your office, then admit them to the hospital because the condition requires more acute attention? Reporting two evaluation and management codes representing the different sites of service has not been an option in the past—but that may be about to change, depending on your payer.

Discover when you can report two evaluation and management codes, and when you should consolidate both visits into one E/M code this year.

The Old Way: Rolling Two E/Ms Into One Code

Prior to January 1, 2023, CPT and most insurers required providers to bundle all E/M services performed on a particular day for the same patient into a single E/M code.

In black and white: CPT 2022 stated, “When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.”

This requires the coder to combine the elements of the office visit (99202-99215) with that of the inpatient visit and determine an appropriate inpatient code (99221-99223) based on the combined criteria.

For example: An established COPD patient presents to your office complaining of a cough with blood in her sputum. On examination, the physician determines the patient is suffering from pneumonia and believes she requires a BiPAP and intravenous antibiotics, so he admits her directly to inpatient status. For this visit in 2022, the doctor would add together the notes from the outpatient visit and the hospital visit to come up with one inpatient E/M code.

Because the notes indicated that the physician spent 20 minutes with the patient at the office and 40 minutes with the patient in the hospital, the coder would be likely to report 99222 (Initial hospital care, per day…Typically, 50 minutes are spent…) for this visit, depending on whether the inpatient documentation included notes about counseling/coordination of care, since that was required for inpatient coding based on time in 2022. If not, you’d need to tally the elements of history, exam, and medical decision-making for the inpatient visit since those were still in play during 2022.

The New Way: Billing Two E/M Codes With Modifier 25

One major change to CPT 2023 involves an update to the same-day E/M rule. Instead of rolling the office visit and admit into one another, you’ll now have the option to report two separate codes, with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended.

In black and white: The 2023 E/M guidelines from CPT state, “When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.”

This means you can report two separate evaluation and management codes, saving the time you would have spent trying to combine the elements from two separate visits into one inpatient service. Plus, because the inpatient codes were updated for 2023 and no longer require you to tally history, exam, and medical decision making, you can base the hospital visit on time or medical decision-making alone.

For example: Using the scenario above regarding the COPD patient, the provider could report both the outpatient and inpatient E/M codes based on time spent with the patient, as follows:

  • 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient…When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded) to represent the 40-minute inpatient visit.
  • 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient…20-29 minutes of total time…) to represent the 20-minute outpatient encounter.

Of course, if you’re using medical decision making as your code selection criteria, the codes you select may be different than these, which would only apply if you’re strictly using time to select the code.

What Does Medicare Say?

Medicare payers are not yet adopting CPT’s guidance about reporting two separate codes for the separate E/M visits. Therefore, when you see a Medicare patient in 2023, you’ll still roll the outpatient elements into your inpatient notes to create one E/M code rather than reporting two.

To ensure you have a handle on the E/M changes for 2023, check out the online training Master New 2023 E/M Coding Changes Before Jan. 1 Deadline. During this 60-minute session, coding expert Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, will walk you through the E/M updates so your claims will sail through the approval process with flying colors in the new year.


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