What is CPT?
In Medical Coding, Current Procedural Terminology (CPT) codes are used to describe medical procedures and were introduced by the American Medical Association (AMA) in 1966. These five-digit codes are divided into three categories: Level I, Level II and Level III. Each category has different modifiers that describe the procedure performed. These modifiers must be used correctly to ensure that payments are accurate and that a physician’s office receives the most reimbursement for all services. CPT codes are used to report services performed by all types of medical providers in the US.
This means that a Medical Coder can use the CPT codes for any service – not just a specific specialty. Some are used only occasionally, while others are never used at all. General check-ups, for example, are covered by CPT codes 99213 and 99214. Without CPT coding, hospitals and other healthcare organizations would have no way to keep track of their data and avoid costly mistakes. Mistakes in CPT coding can result in wrong billings, miscommunication between departments and other problems. These errors can affect the entire revenue cycle.
Physicians use CPT evaluation and management (E/M) codes to bill their medical services. These codes have guidelines that physicians must follow. For example, E/M codes do not include travel time or any time spent performing procedures that are not related to the patient’s health. Medical Coders are responsible to code for the physician. CPT E/M codes have gone through significant changes since the 1997 revision. Knowledge of E/M coding ensures optimal compliance and avoids inadvertent undercoding. Physicians with a solid understanding of the E/M documentation can command higher rates of return. CPT codes are subject to revisions and changes yearly.
2023 will bring sweeping changes for the E/M and consultation codes. The changes, in addition to removing confusing guidelines and a definition of “transfer of care,” these codes will be de-duplicated to align with the new four levels of MDM. Nursing facility services will be re-coded with similar documentation rules. Physicians will now select a level of care based on medical decision-making (MDM). Previously, total time was used to determine the level of care that a physician must provide. The new rules also include updates to documentation standards. The proposed changes will affect many different areas of Medical Coding, including hospital inpatients, observation care visits, emergency room visits, nursing facility services and home visits. AI and virtual care codes will be revised. These revisions will improve the documentation requirements for telemedicine, telephone services and outpatient services.
Some codes are being phased out while others will undergo revisions. There are to be close to 400 changes in 2023, including 225 new codes, 75 deletions and 93 revisions. The changes to the Medicare system are a good thing for all healthcare providers. In the long run, this will improve the quality of care and decrease the risk of fraud and abuse. The changes were created to reduce administrative burdens and focus on patient care. Currently, physicians are burdened with so much paperwork, that their time is taken away from patient care. The new guidelines will also affect the way a physician chooses an E/M code. All changes will go into effect on Jan. 1, 2023.
Here is a quote from Jack Resneck Jr, MD, President of the AMA:
“The process for coding and documenting almost all E/M services is now simpler and more flexible. We want to ensure that physicians and other users get the full benefit of the administrative relief from the E/M code revisions. The AMA is helping physicians and [healthcare] organizations prepare now for the E/M coding changes and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”
According to the AMA, the updates by care setting or service are as follows:
Inpatient and observation care services
- Deletion of observation CPT codes (99217 through 99220 and 99224 through 99226) and merged them into the existing hospital care CPT codes (99221 through 99223, 99221 through 99233, and 99238 through 99239)
- Revision of the code descriptors to account for the structure of total time on the date of the encounter or level of medical decision-making when selecting code level
- Retention of revised observation or inpatient care services, including admission and discharge services (CPT codes 99234 through 99236)
- Retention of the consultation codes, with some editorial revision to the code descriptors
- Deletion of certain guidelines deemed confusing by the AMA, including the definition of “transfer of care”
- Deletion of lowest level office (99241) and inpatient (99251) consultation codes to align with four levels of MDM
Emergency department services
- Retention of the existing principle that time cannot be used as a key criterion for code level selection
- Revisions to the code descriptors to reflect the code structure approved in the office visit revisions
- Modified MDM levels to align with office visits and maintain unique MDM levels for each visit
- Retention of existing CPT code numbers
- Updates to current practice that was not explicit in the CPT code set, which may be used by physicians and other qualified healthcare professionals other than ED staff
- Allowance of critical care to be reported in addition to ED service for clinical change
Nursing facility services
- Revision to nursing facility guidelines with a new “problem addressed” definition of “multiple morbidities requiring intensive management,” to be considered at the high level for initial nursing facility care
- Deletion of code 99318 (annual nursing facility assessment), which will be reported through the subsequent nursing facility care services (CPT codes 99307 through 99310) or Medicare G codes
- Updated standard so not all “initial care” codes are the mandated comprehensive “admission assessment” and may be used by consultants
- Allowance of the use of subsequent visit when the principal physician’s team member performs care before the required comprehensive assessment
Home and residence services
- Deletion of the domiciliary or rest home CPT codes (99334 through 99340), which have now been merged with the existing home visit CPT codes (99341 through 99350)
- Elimination of the duplicate MDM Level New Patient code (99343)
- Deletion of direct patient contact prolonged service codes (99354 through 99357), which will be reported through either the code created in 2021, office prolonged service code (99417), or the new inpatient or observation or nursing facility service code (993X0)
- Creation of a new code (993X0) to be analogous to the office visit prolonged services code (99417)
- Retention of 99358 and 99359 for use on dates other than the date of any reported ‘total time on the date of the encounter” service
“The new AI taxonomy establishes foundational definitions and a shared understanding among stakeholders that clearly describes the technical features and performance of AI applications, as well as the work performed by the machine on behalf of the health care professional,” said Resneck. “This shared understanding will help guide the CPT editorial process for describing the range of AI products and services.” -Jack Resneck Jr, MD, President of the AMA.
Being Prepared for the Changes
Before the implementation of the new CPT codes, Medical Coders should familiarize themselves with the new codes. The CPT code set is the trusted language of medicine today and learning the proposed changes early will help all healthcare professionals stay up-to-date, especially Medical Coders. Study these changes so you can be thorough when these changes begin.