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Understanding E&M codes and getting the latest updates

With the year winding down, now is a good time for healthcare practices and billing companies (on behalf of their clients) to ensure compliance with billing code changes that took effect October 1, 2023, and prepare for changes that become effective January 1, 2024. Discover what’s new for evaluation and management (E/M) codes and ICD-10-CM diagnosis codes that could affect your medical practice.

Medical billing manager learns about m codes icd 10 for 2023 and 2024

At a Glance

  • CPT code changes taking effect in 2024 include removing time ranges from E/M codes 99202-99205 and 99212-99215, and providing a new definition for split/shared E/M visits.
  • ICD-10-CM code changes effective Oct 1, 2023 provide greater specificity for conditions like resistant hypertension, metabolic disorders, and more.
  • To prepare for the code changes, practices should focus on coder education, loop in physicians on documentation needs, and audit claims to ensure compliance and prevent denials.

Understanding E&M codes and staying updated on relevant changes are an important part of modern healthcare. Using the correct codes is essential to minimizing billing errors and avoiding financial penalties and audits. A thorough understanding of E&M codes helps practices streamline billing processes and promote better patient outcomes through accurate recording of medical information.

The role of E&M codes in healthcare

E&M codes standardize the documentation and billing process for patient encounters. To help with precise reimbursement and quality evaluation, these codes classify visits according to their complexity and the resources used. They help healthcare providers receive the proper compensation and make it easier for professionals to communicate regarding patient care and treatment plans. Keep reading to gain a comprehensive understanding of E&M codes and to learn about the latest changes and updates.

E&M codes and medical billing

In medical billing, E&M codes serve as the backbone of reimbursement processes, linking the services provided to the appropriate charges. They classify the level of service rendered during patient encounters so billing specialists can assign accurate fees and reimbursement. Proper documentation of E&M codes guarantees compliance with coding regulations and optimizes revenue cycle management for healthcare facilities.

Other types of coding are used in the healthcare industry to work with E&M codes, including: 

  • Occurrence codes, which are used to report specific events or circumstances related to a patient's care, such as inpatient or outpatient hospital treatments. These codes are typically used to indicate occurrences such as the start or end of a service, changes in a patient's condition, or other events relevant to insurance company billing and reimbursement.
  • Taxonomy codes, which are to classify healthcare providers and practitioners based on their specialty or area of practice. These codes are used for administrative purposes like insurance claim processing, provider enrollment, and healthcare provider directories.

HCPCS codes, which are used to identify specific medical procedures, diagnostic tests, durable medical equipment, drugs, and other healthcare services provided during or in association with an E&M visit. For example, if a patient undergoes a specific diagnostic test or receives a particular medication during an office visit, the appropriate HCPCS code(s) would be reported alongside the corresponding E&M code to accurately document and bill for all services rendered.

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Decoding E&M codes: Procedure codes, diagnosis codes and more

When discussing E&M codes, a digit code refers to the numerical representation used to categorize and identify specific types of medical services within the code set. Each E&M code consists of a series of digits that convey information about the level of complexity and resources required for a patient encounter. The Current Procedural Terminology (CPT) code set includes codes for services other than E&M, including radiologic imaging and operations.

Procedure codes specify the services rendered during patient encounters. Diagnosis codes identify the patient's condition or reason for the visit. Together, procedure and diagnosis codes complement E&M codes by offering comprehensive documentation of the patient encounter, including the services performed and the medical reasons behind them.

The following groups are part of the E&M coding system:

  • (99202–99215) Office/other outpatient services
  • (99217–99226) Hospital observation services
  • (99221–99239) Hospital inpatient services
  • (99241–99255) Consultations
  • (99281–99288) Emergency department services
  • (99291–99292) Critical care services
  • (99304–99318) Nursing facility services
  • (99324–99337) Domiciliary, rest home (boarding home), or custodial care services
  • (99339–99340) Domiciliary, rest home (assisted living), or home care plan oversight services
  • (99341–99350) Home health services
  • (99354–99417) Prolonged services
  • (99366–99368) Case management services
  • (99374–99380) Care plan oversight services
  • (99381–99429) Preventive medicine services
  • (99450–99458) Special evaluation and management services
  • (99460–99463) Newborn care services
  • (99466–99486) Inpatient neonatal intensive and pediatric/neonatal critical care services
  • (99495–99496) Transitional care evaluation and management services
  • (99497-99498) Advance care planning evaluation and management services
  • (99499) Other evaluation and management services

The impact of code modifiers on E&M codes

Code modifiers ensure accuracy in coded claims by indicating unique aspects of patient encounters that might affect reimbursement or treatment decisions. Medical coding professionals use modifiers to distinguish between different levels of complexity or to denote special situations not fully captured by specific codes. For instance, modifier 25 is necessary when a significant E&M service is provided on the same day as another procedure. This ensures appropriate reimbursement and avoids denial of claims. Similarly, modifier 24 is used during the postoperative period to indicate an E&M service unrelated to the initial surgery. These modifiers help accurately bill and track revenue codes while complying with coding regulations and obtaining approval codes for reimbursement.

ICD-10 and its relation to E&M codes

The International Classification of Diseases, 10th Revision (ICD-10) uses alphanumeric codes to categorize illnesses, injuries, and other health issues. ICD-10 codes help to document patient diagnoses and the reasons for encounters.

The proper assignment of ICD-10 codes alongside E&M codes is essential for accurate billing and reimbursement. ICD-10 codes also contribute to quality reporting initiatives by capturing data on patient diagnoses and outcomes associated with specific E&M services. This enhances performance evaluation and quality improvement efforts.

Differences between ICD-9 and ICD-10

The transition from ICD-9 to ICD-10 in E&M coding brought significant changes to medical coding practices. ICD-10 offers more specificity with alphanumeric codes, allowing for detailed documentation of diagnoses in medical records compared to the numeric codes of ICD-9. This increased specificity enables healthcare providers to use specific care codes that accurately represent patient conditions. Additionally, ICD-10 provides alternative codes for greater precision while accommodating new diagnoses and procedures. Healthcare professionals must be careful to use valid ICD 9/10 CM codes to maintain compliance, accurately represent patient encounters, and obtain appropriate reimbursement.

Special considerations for specific provider types

A provider specialty code refers to a specific code that designates the medical specialty or area of practice of a healthcare provider. A primary care physician may use different E&M codes than a specialist, like a cardiologist or neurologist. Understanding the nuances of provider specialty codes helps professionals to accurately select the appropriate service codes that align with the care provided. Here are some examples of medical specialties and how they might use E&M codes for medical billing:

  • Primary care physicians (PCPs). May frequently use lower-level E&M codes for routine office visits.
  • Specialists. Often require higher-level E&M codes due to the complexity of their patients' conditions.
  • Surgeons. Use E&M codes in addition to procedure codes for pre-operative and post-operative evaluations.
  • Emergency medicine physicians. Frequently use E&M codes for urgent care visits, with a focus on rapid assessment and treatment.
  • Pediatricians. May use specific E&M codes tailored to childhood developmental assessments and vaccinations.

Geriatricians. May use higher-level E&M codes due to the complexity of managing multiple chronic conditions in elderly patients.

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Changes and updates to coding

Medical code changes happen every year, and it can be overwhelming to keep track of what codes are new, revised, and deleted. Let's look at some important changes to evaluation and management (E&M) codes that took effect January 1, 2024, as well as several ICD-10-CM diagnosis code changes that became effective October 1, 2023. Our goal is to help you ensure clean claims, reduce denials, and promote revenue integrity in your medical practice.

<h2>Notable changes to E&M codes

In the 2024 CPT code update, you’ll find notable E&M-related changes for:

  • Codes 99202-99205 and 99212-99215. The American Medical Association (AMA) removed time ranges from these codes to align their format with that of other E&M codes.
  • Split/shared E&M visits. The AMA provides a new definition to determine the substantive portion of a visit in which a physician and non-physician practitioner work jointly to furnish all of the work related to the visit.

In total, the annual update to the CPT code set created 349 editorial changes, including 230 additions, 49 deletions, and 70 revisions. This includes the consolidation of more than 50 previous codes that streamline the reporting of immunizations for COVID-19.

The CPT Editorial Panel also approved the provisional codes (91318-91322) to identify monovalent vaccine products from Moderna and Pfizer for immunization against COVID-19.

Want to learn more about the changes? Take a look at this AMA press release and monitor the CMS website for an updated code list. You can also read this AMA article and definitely be sure to purchase a 2024 CPT Manual

Notable changes to ICD-10-CM codes

The fiscal year (FY) 2024 ICD-10-CM code updates that took effect October 1, 2023 includes 395 code additions, 25 code deletions, and 13 code revisions. Here are some of the most notable changes:

1. Resistant hypertension

A new ICD-10-CM diagnosis code for resistant hypertension (I1A.0) captures cases where a patient’s hypertension does not respond well to aggressive medical treatment. 

2. Metabolic disorders and insulin resistance

Four new codes for metabolic disorders replace ICD-10-CM diagnosis code E88.81 (metabolic syndrome): 

  • E88.810 - Metabolic syndrome, dysmetabolic syndrome X
  • E88.811 - Insulin resistance syndrome, Type A
  • E88.818 - Other insulin resistance, Insulin resistance, Type B
  • E88.819 - Insulin resistance, unspecified

3. Chronic migraines

New ICD-10-CM diagnosis code for chronic migraine with aura (G43.E) provides additional specificity in terms of "intractable vs. not intractable" and "with or without status migrainosus." 

4. Parkinson’s disease

Four new, more specific ICD-10-CM diagnosis codes for Parkinson’s disease replace ICD-10-CM code G20 (Parkinson’s disease):

  • G20.A1 - Parkinson's disease without dyskinesia, without mention of fluctuations
  • G20.A2 - Parkinson's disease without dyskinesia, with fluctuations
  • G20.B1 - Parkinson's disease with dyskinesia, without mention of fluctuations
  • G20.B2 - Parkinson's disease with dyskinesia, with fluctuations

There’s also a new ICD-10-CM diagnosis code for unspecified Parkinsonism (G20.C). This is a general healthcare term for a group of neurological disorders causing movement problems similar to those seen in Parkinson’s disease (e.g., tremors, slow movement, and stiffness).

5. Pneumonia

CPT no longer includes ICD-10-CM diagnosis code J15.6 (pneumonia due to other gram-negative bacteria). Instead, report 1 of these 2 new, more specific medical codes:

  • J15.61 - Pneumonia due to Acinetobacter baumannii
  • J15.69 - Pneumonia due to other Gram-negative bacteria

6. Dense breasts

There’s a new ICD-10-CM diagnosis code for dense breasts, unspecified (R92.3). 

7. Child custody

Be sure to put these 2 new ICD-10-CM diagnosis codes on your radar:

  • Z62.23 - Child in custody of non-parental relative
  • Z62.24 - Child in custody of non-relative guardian

8. Familial conflict

Similarly, make sure you’re aware of these 5 new ICD-10-CM diagnosis codes for conflicts children may have with relatives or guardians:

  • Z62.823 - Parent-step child conflict
  • Z62.83 - Non-parental relative or guardian-child conflict
  • Z62.831 - Non-parental relative-child conflict
  • Z62.832 - Non-relative guardian-child conflict
  • Z62.833 - Group home staff/child conflict

9. Caregiver noncompliance

Finally, note that there are 2 new ICD-10-CM diagnosis codes for noncompliance due to financial hardship:

  • Z91.A41 - Caregiver’s other noncompliance with patient’s medication regimen due to financial hardship
  • Z91.A51 - Caregiver's noncompliance with patient’s renal dialysis due to financial hardship

3 strategies to prepare for the changes

Consider these 3 strategies to ensure a compliant healthcare revenue cycle and promote revenue integrity in your medical practice:

1. Focus on coder education

Make sure coders understand the new codes and review the FY 2024 ICD-10-CM official guidelines for coding and reporting that provide additional reporting instructions. In this article, we’ve only provided a snapshot of the changes. There are plenty of other new codes that may also affect your medical practice and specialty. 

2. Loop physicians into the changes 

Educate physicians and other providers who document in the medical record to ensure their documentation supports the additional specificity inherent in many of the new codes. 

3. Audit claims

The new ICD-10-CM diagnosis codes have been in effect for some time. If you have not audited claims, now is a good time.

Report new codes with confidence to avoid denials

Understanding new medical codes can pose a challenge. However, with a bit of proactive planning and education, coders, physicians, and others will be able to report new codes with confidence and avoid denials.

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Lisa Eramo, freelance healthcare writer

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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