Important 2023 E&M Code Changes for Prolonged Services

Among the changes are a new code for reporting prolonged services in the inpatient or observation setting and significant guideline revisions.

EDITOR’S NOTE: The American Medical Association (AMA) recently announced major revisions to Evaluation and Management (E&M) Services, effective Jan. 1, 2023. The E&M categories that will undergo revision in 2023 include inpatient and observation care services, emergency department services, consultations, nursing facility services, home and residence services, and prolonged services.

For 2023, revisions to the E&M category Prolonged Services include a deleted subcategory and E&M codes within that subcategory, a revised title for two subcategories, and a new code for reporting prolonged services in the inpatient or observation setting, along with significant guideline revisions.

The subcategory Prolonged Service with Direct Patient Contact (Except with Office or Other Outpatient Services) has been deleted for 2023.  The CPT® codebook provides parenthetical notes to report prolonged services on the date of the encounter for outpatient, home, or residence service, or cognitive assessment and a care plan, with E&M code 99417 – or, for prolonged services in an inpatient, observation, or nursing facility setting, with the new E&M code 993X0. 

The E&M subcategory Prolonged Service Without Direct Patient Contact has been revised to Prolonged Service on Date Other Than the Face-to-Face Evaluation and Management Service Without Direct Patient Contact. There remain two E&M codes in this subcategory: 99359 for the first hour and 99359 for each additional 30 minutes. These two codes:

• Are used when a prolonged service is provided on a date (before or after) other than the date of the face-to-face E&M service;
• Can be used to report prolonged service for any E&M service, whether or not time was used to select the level of service;
• Must be related to a service or patient for whom face-to-face patient care has occurred or will occur, related to ongoing patient management; and
• Prolonged service of less than 30 minutes duration on a given date is not separately reported.

As noted, for 2023, a new E&M code is being established for reporting prolonged services in the inpatient, observation, or nursing facility settings. This new E&M code, 993X0, will be in the subcategory Prolonged Service With or Without Patient Contact on the Date of an Evaluation and Management Service. This subcategory will have two E&M codes: the existing 99417, used to report prolonged total time on the date of office or other outpatient services, and 993X0 for reporting prolonged services in the inpatient, observation, or nursing facility settings. Both 99417 and 993X0 are used:

• When the primary service has been selected using time as the basis for level selection;
• When the total time is 15 minutes beyond the time required to report the highest-level primary service; and
• Only after the time required to report the highest-level service has been exceeded by 15 minutes.

From a Centers for Medicare & Medicaid Services (CMS) perspective, the 2023 Medicare Physician Fee Schedule (PFS) Proposed Rule intends to adopt the revised CPT® E&M Guidelines for Other E&M visits, the general CPT framework for Other E&M visits, such that the physician or non-physician practitioner (NPP) would use time or medical decision-making (MDM) to select the E&M visit level. CMS proposed to adopt the listing of qualifying activities by the physician or NPP that count toward the time spent when time is used to select the visit level, along with adopting that the history and physical exam would be considered, as medically appropriate, and would no longer be used to select the level of service.

CMS did not adopt the general CPT® rulewherein a billable unit of time is considered to have been attained when the midpoint is passed (for example, CMS would not consider a service with a time descriptor of 30 minutes to have been satisfied if only 15 minutes of time had been spent furnishing that service). CMS requires the full time within the CPT code descriptors to be met to select an Office E&M visit level using time, rather than half of the descriptor time.

The CMS Medicare PFS Proposed Rule does not propose to adopt CPT code 993X0; they believe that the coding and reporting instructions for it will “lead to administrative complexity, potentially duplicative payments, and limit our ability to determine how much time was spent with the patient using claims data.”

CMS is proposing three new G codes for reporting prolonged services for 2023:

• GXXX1 – Prolonged hospital in patient or observation care, E&M service beyond the total time for the primary service;
• GXXX2 – Prolonged nursing facility E&M service beyond the total time for the primary service; and
• GXXX3 – Prolonged home or residence E&M service beyond the total time for the primary service.

Below is the table from the CMS Medicare Physician Fee Schedule Proposed Rule found in the Federal Register.