E/M Changes in 2024: A Comprehensive Guide

The 2023 Evaluation and Management (E/M) classification guidelines were revised and expanded by the American Medical Association (AMA) in collaboration with the centers for Medicare and Medicaid services (CMS) beginning in January 2023. This extension involved the ongoing selection of the code for outpatient E/M office visits under CPT 99202-99215, based on either time or Medical Decision Making (MDM). The same guidelines apply to the following services: Emergency Department (99281-99285), Hospital Inpatient and Observation Care Services (99221-99233), Inpatient and Outpatient Consultations (99242-99255), New and Established Home or Residence Services, and Initial and Subsequent Nursing Facility Care. This allows providers to determine their code level based on MDM or time. Numerous modifications will continue to endure in 2024.
What information is essential for physicians to be aware of regarding changes in E/M in 2024?

Initially, clinicians should bear in mind that they are adhering to a single set of guidelines for multiple locations. In this article, we will delve into all the changes that providers need to be aware of, which include:

For both new and established patients, the hours of office outpatient care have changed.
Hospital inpatient or observation care services encompass both admission and discharge processes.
Guidelines for Split-Shared Visits.

What Should You Know About E/M Changes in 2024?

One significant change in 2024, as outlined by the AMA, is that the time is now specified as “must be met or exceeded” rather than a start and end time for E/M codes in the categories mentioned above.

Example 2023: Dr. Jones observes an established patient in the office and intends to assign an E/M code after spending 36 minutes with the patient. For this visit, we would choose level 4-99214, which is based on the total time spent on the date of the encounter, between 30 and 39 minutes.

In 2024, Dr. Jones will encounter the same patient in the office and intends to assign an E/M code after spending 30 minutes with the patient. For this visit, we would choose level 4-99214, which is contingent upon completing or exceeding 30 minutes.

What Should You Know About E/M Changes in 2024?

The length of stay (including admission and discharge) will determine the choice of E/M codes for hospital inpatient or observation care services, with the AMA providing guidance in 2024. When the stay exceeds eight hours, the following grid assists clinicians, medical billers, and medical coders in reporting hospital inpatient or observation care services provided to patients admitted and discharged on the same service date. These services are exclusively used by the physician or qualified healthcare professional team responsible for providing initial and discharge services.

For instance, on a Thursday in 2024, Dr. X admits Mrs. S to observation for a severe headache at 2 a.m. Later in the day, Dr. X visits Mrs. S, who is now feeling significantly better and stable as a result of the treatment with IV fluids and medication. Mrs. S was discharged at 12:00 p.m. Dr. X will bill E/M codes 99234-99236 according to the MDM or time. 

If Mrs. S was discharged within eight hours, Dr. X would bill her with E/M codes 99221-99223.

Reduce administrative difficulties, prioritize patient care, and stay ahead of E/M changes.

Points to Consider in 2024

1. History and/or examination are not included in the code selection process.

After the implementation of the E/M changes in 2023, it is no longer necessary to determine the extent of the history and physical examination. The provider will be responsible for conducting and documenting the history and physical examination that they consider medically necessary for the patient during the visit.

2. Comparison of Medical Decision Making and Total Time Spent

Medical practitioners and other competent healthcare professionals can now determine the suitable level of evaluation and management (E/M) service by considering one of the following criteria:

Each service has a defined level of medical decision-making (MDM).

The provided information states the overall duration of E/M services conducted on the specific date of the encounter.

Providers must select either MDM or time, but they cannot choose both simultaneously. The choice of method to use will be determined by the provider’s discretion.

Allow us to examine and assess each individual segment of the medical decision-making table. As per the initial modifications to the E/M guidelines in 2021, medical decision-making encompasses the tasks of establishing diagnoses, evaluating the condition’s status, and/or choosing a management option.

• The definition of medical decision-making in the seven service code sets listed above is based on three key components:
• During the evaluation and management encounter, the healthcare provider deals with a variety of problems that vary in their level of difficulty.
• The magnitude and/or intricacy of the data require examination and evaluation.
• Risks of complications, morbidity, and/or mortality are associated with the patient management decisions made during the visit. These decisions may be influenced by the patient’s issues, diagnostic procedures, or treatment.
• Refer to the document titled “AMA Code, Definitions, and Guidelines Changes” on pages 8–9 of the 2024 edition of the Current Professional Terminology (CPT) book.

Providers were previously required to document medical decision-making (MDM) at one of four levels: straightforward, low complexity, moderate complexity, or high complexity, according to the previous E/M guidelines. We have modified the MDM table of risk to focus on activities that have an effect on the management of a patient’s condition, while still including the four types of medical decision-making categories. It is important to understand that the overall MDM level only necessitates two out of the three MDM elements. 

3. Number and Complexity of Problems Addressed During the Encounter

During the encounter, the physician or other qualified health care professional reporting the service addresses or manages a problem, also known as our diagnosis.

To receive credit for the problem or treatment, the provider must demonstrate that they have evaluated the issue. It is important to note that simply recording stating that another professional is handling the problem without any additional assessment or coordination of care does not meet the criteria for the physician or qualified health care professional to be considered as “addressing” or “managing” the issue. 

Key terms to consider

Minor or self-limiting problems

• Stable chronic 
• Acute, uncomplicated illness or injury 
• Undiagnosed new problem with uncertain prognosis 
• Chronic illnesses characterized by severe exacerbations, progression, or treatment side effects

4. Quantity and/or intricacy of data to be examined and analyzed

This dataset comprises medical records, tests, and/or other information that must be acquired, requested, examined, and analyzed for the patient encounter. These cannot be the provider’s own notes. The provider must review and analyze his or her notes without simply copying or pasting them into the medical record. 

Data is divided into three categories

• Tests, documents, orders, or independent historian(s). We count each distinct test, order, or document toward a threshold number.
• Independent interpretations of tests.
• Discuss management and/or test interpretations with an external physician, another qualified healthcare professional, or a suitable source.

Data encompasses information acquired from various sources or through interprofessional communication that is not reported individually. For instance, this section cannot use data from an office-based EKG provider who billed for it.

On the other hand, if a provider receives an MRI report for a diagnostic center and then reviews images or interprets that report during or just before the patient encounter, then the provider will receive credit only if images are reviewed and the provider states they did their own interpretation. If the provider orders the test and only reviews the report on a second visit, he/she is not able to count in the data. The first visit counts both the order and the read.

5. Risk of complications, morbidity, and/or mortality

This includes the risk of complications, morbidity, and/or mortality associated with patient management decisions made during the visit that relate to the patient’s problem(s), diagnostic procedure(s), and/or treatment(s).

This encompasses the management options that were chosen, as well as the options that were deliberated but ultimately not chosen, following a collaborative process of medical decision-making involving the patient and/or their family. 

The American Medical Association (AMA) has supplied the following examples for reference: The AMA defines “a decision about hospitalization or escalation of hospital-level care.”

Examples may include

a mentally ill patient who has adequate support in an outpatient setting or a decision not to admit a patient with advanced dementia who has a severe condition that would normally require hospitalization but whose purpose is to provide palliative care.

6. Risks Associated with “Social Determinants of Health” are also Addressed

You may be familiar with SDOH from ICD-10-CM coding, specifically categories Z55.- to Z65.-, which refer to persons with potential health hazards related to socioeconomic and psychosocial circumstances. It is important to note that the AMA has supplied a table for CPT E/M office revisions. You can assign the correct CPT code with the help of the level of medical decision-making (MDM) chart, fully updated for E/M changes in 2024. 

7. Documentation Considerations

The nature of the event under consideration determines the assessment of the level of risk.

For instance, a stable, chronic illness occurs when a patient’s treatment goals determine whether the illness is stable. Even if their condition has not changed and there is no immediate threat to life or function, a patient who has not reached their treatment goal is not stable.

Risk definitions are based on the typical behaviors and thought processes of a physician or another qualified health care professional in the same specialty. For the purposes of medical decision-making, the level is based on the consequences of the problem(s) addressed during the encounter when appropriately treated. Risk also encompasses medical decision-making regarding whether to proceed with or abstain from additional testing, treatment, or hospitalization. Be aware that the documentation must still demonstrate medical necessity.

8. Duration of Time Spent 

The second option for choosing the correct CPT codes relies on the overall duration of the encounter on the specific date, excluding emergency room services, for the aforementioned service levels.

For coding purposes, time for these services is the total spent on the date of the encounter, face-to-face and non-face-to-face, with the patient. The medical note must document the time for each activity to accurately reflect the actions taken. The total time will encompass all the time that the physician and/or other qualified healthcare professionals personally dedicate to the patient’s care on the date of the encounter. 

If time is used to specify the appropriate level for E/M service codes, be aware that time is defined by the service descriptors. 

The following are examples of timed activities you could perform

• Engaging in pre-consultation activities such as reviewing test results in anticipation of the patient’s visit.
• Obtaining and/or reviewing separately obtained history. 
• Performing a medically appropriate examination and/or evaluation 
• Counseling and educating the patient, family, or caregiver. 
• Ordering medications, tests, or procedures 
• Interacting and exchanging information with other healthcare professionals (without reporting it separately)
• Recording clinical data in the electronic or other health record
• Analyze findings autonomously (without being reported separately) and effectively convey the results to the patient, their family, or their caregiver.
• There is no separate report for care coordination.

9. Shared/Split Visits

Split or shared evaluation and management (E/M) visits are medical appointments that involve both physicians and nonphysician practitioners and take place in various institutional settings, such as hospitals and skilled nursing facilities (SNF). The changes to the Current Procedural Terminology (CPT) guidelines for CY 2024 will include the definition of a “substantive portion” of a split (or shared) visit. For Medicare billing purposes, a “substantive portion” refers to a significant portion of the medical substantive portion of a split (or shared) visit, or more than half of the total time the physician or non-physician practitioner spends performing the split (or shared) visit.

Additionally, CMS requires documentation to identify the two individuals who performed the service, and the billing professional must sign and date the record.

10. Split Shared in Layman Terms

In layman’s terms, CMS will determine the substantive portion based on the practitioner who spends more than 50% of the time or the practitioner who performs and approves the medical decision-making (MDM). When both practitioners spend time with the patient together, they can only count it once. Provider types include MD, DO, PA and NP when patients are seen in place of service 19 at an off-campus outpatient hospital or 22 at an on-campus outpatient hospital. Only billing-related incidents can occur in outpatient offices.

Consider the following examples: 

For instance, if the NPP initially spent 7 minutes with the patient and the physician then spent an additional 10 minutes, the sum of their individual time would equal a total of 17 minutes. We would bill the physician for this visit because they contributed more than half of the total time (10 of the 17 total minutes). In the same scenario, if the physician and NPP convened for an additional eight minutes (beyond the 17 minutes) to discuss the patient’s treatment plan, we could only count this overlapping time once to determine the total time and identify the individual responsible for the substantive portion of the visit. The total duration of the visit would be 25 minutes, and the physician would receive payment for it, as they accounted for more than half of this time (18 out of 25 total minutes).

In order to bill for a split or shared subsequent hospital service, the billing practitioner should report CPT code 99231, provided that the coding is based on time. In the calendar year 2024, when not considering time, bill CPT codes 99231-99233 as they satisfy the essential level of key components on which the coding is founded. The billing practitioner is required to carry out and record medical decision-making.

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 Conclusion

It is evident that all parties involved in submitting claims, such as providers, coders, and EMR vendors, must receive thorough training regarding the E/M modifications for the first seven sections of E/M Services in 2024.

The main objective of these E/M changes is to simplify the process of documenting. The objective is to diminish the administrative workload and enhance the duration that physicians can allocate to patient care. It is important to remember that medical coding should accurately represent the events of the medical encounter and provide evidence for the medical necessity. Providers should maintain the connection between ICD-10-CM diagnosis codes and identify any social health determinants that could impact the patient’s treatment. Always endeavor to record diagnosis codes with the utmost precision and specificity.

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