Evaluation and management code changes in 2021 & 2023

Nurse practitioners should be aware of the recent evaluation and management code changes.

In 2021, significant changes were made to the outpatient evaluation and management codes and in 2023 similar updates were made to inpatient/observation, ER, and skilled nursing facilities. The last time any updates were made was in 1995 and 1997. So the updates were much needed! 

Choosing the proper evaluation and management CPT® code for each patient encounter is something that is extremely important as a nurse practitioner. These codes are used to bill the patient’s health insurance and generate income for the healthcare institution.

Many nurse practitioners did not get enough education/information while in school. Choosing the correct evaluation and management code is something many nurse practitioners have to learn themselves. 

This article will focus on a few tips for implementing these updates and take a look at what the actual changes include. For a deeper dive to the evaluation and management code changes in 2021 and 2023, check out The Basics of Billing and Coding Course created by The Nurse Practitioner Charting School. 

Tips for evaluation and management code changes

 Here are some tips for selecting evaluation and management CPT® codes for patient encounters:

1. Familiarize yourself with the evaluation and management code changes. The E/M guidelines have specific updates to each practice setting. So it is important to review the guidelines for hospital vs. ER vs. nursing homes vs. outpatient clinic visits before selecting a code. The guidelines provide information on the documentation requirements, key components for code selection, and time-based criteria.
2. Review the medical record thoroughly. To select the appropriate evaluation and management code, you need to have a complete understanding of the patient’s medical history and current condition. Be sure to review all relevant medical records, including the history and physical examination, progress notes, diagnostic test results, and treatment plans. Reviewing this medical information can be used to help choose the correct evaluation and management code. 
3. Choose a method for coding. The 2021 and 2023 evaluation and management code changes now allow healthcare providers to code by time or medical decision making. Determine which method you will use to code the patient encounter. The chosen method may differ from the next patient. It is important to know how to code by both time and medical decision making so the highest yet accurate evaluation and management code can be chosen. This article will further discuss the updates of evaluation and management code changes. 
4. Code to the highest level supported by the documentation. When selecting an evaluation and management code, always code to the highest level supported by the documentation. If the documentation does not support a higher level of service, then code to the level that is supported. We are not looking to create fraudulent claims but rather chose the correct evaluation and management code. 
5. Choose the accurate evaluation and management code. Remember that accurate and appropriate E/M coding is crucial for ensuring that providers are reimbursed fairly for their services. If you have any doubts about selecting the appropriate code, consult with a coding specialist or your billing department. If you would like to learn more about choosing the correct evaluation and management code, check out The Basics of Billing and Coding Course. 

2021 and 2023 evaluation and management code changes

In 2021 and 2023, the E/M codes were updated to reflect changes to the way medical professionals document and code their services.

Here are some of the key changes:

1. Removal of history and physical examination as key components for code selection. In the past, providers had to document certain elements of history and physical exams to qualify for a specific code level. Now, the selection of E/M code levels is primarily based on medical decision making or time spent with the patient.
2. Introduction of new codes for prolonged services. The 2021 and 2023 evaluation and management coding changes introduce new codes for prolonged services beyond the typical time for the highest level of service. These codes can be used to report additional time spent by the provider beyond the typical time for a given level of service.
3. Changes to documentation requirements. In order to bill for an evaluation and management service, providers must document a certain level of medical decision making or time spent with the patient. However, the documentation requirements have been streamlined to allow for greater flexibility in how providers document their services.

Two methods to code patient encounters

Coding by medical decision making.

Determine the level of medical decision making. Medical decision making (MDM) is a key component in selecting an E/M code. MDM refers to the complexity of the patient’s medical problem(s) and the level of risk associated with the patient’s management.

To determine the level of MDM, consider the number and complexity of problems addressed during the encounter, the amount and complexity of data reviewed, and the risk of complications or morbidity.

Coding by time.

Choosing the accurate evaluation and management code based on time allows the nurse practitioner to credit any time spent on the date of the patient encounter.

Activities that can be counted when coding by time include:

• Reviewing past medical documentation,
• Assessing the patient,
• Ordering/reviewing test results,
• Patient education,
• Sending prescriptions,
• Documenting in the electronic health record,
• Additional related activities.

Nurse practitioners can now give themselves credit for any of these additional tasks done on the date of the patient encounter. 

**Please note: When choosing the correct evaluation and management code in the ED setting, coding by time can not be used. This is due to nurse practitioner’s time being fragmented, caring for multiple patients at once. 

To learn how to code by medical decision making and time, check out The Basics of Billing and Coding Course.

Additional resources for billing and coding

To code using the 2023 updated E/M codes, providers should ensure that they are familiar with the new documentation requirements and guidelines for selecting codes based on medical decision-making or time spent with the patient. They should also ensure that their billing and documentation systems are updated to reflect the new codes and guidelines. 

To learn more about billing and coding, check out The Basics of Billing and Coding Course created by The Nurse Practitioner Charting School.

This instant access, online course offers 75 minutes of video training (broken down into easy to consume lessons) teaching you the basics of coding in the outpatient, inpatient/obs, ER, and nursing facility setting!

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Lesson topics include:

• Coding and Billing Terminology: Discover the lingo and process of coding and billing patient encounters.
• Introduction to Coding: Learn the things you didn’t learn in nurse practitioner school!
• Coding by Medical Decision Making: A complete breakdown of how to select each evaluation and management CPT® code using medical decision making for outpatient, inpatient/obs, ER, and nursing facility patient visits.
• Coding by Time and Prolonged Services: This lesson covers the coding by time and the 2021 changes to the Evaluation and Management Codes as well as the 2023 changes to the Evaluation and Management Codes.
• Practice Coding Examples: We will discuss real world examples and learn to code using evaluation and management levels 99202-99205 and 99211-99215.

And lifetime access to the course (come back and review at any time)!!

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Also offering continuing education hours!

If you are ready to….

• Implement the actionable information into your current practice
• Feel confident choosing the correct Evaluation and Management code
• And increase your knowledge and overall worth as a nurse practitioner

then The Nurse Practitioner Billing and Coding Course  is for you!