Podcast Episode 13: 2023 Update
Episode Summary: 2023 brings forth new changes in ICD codes, CPT codes (namely E/M Hospital services documentation guideline revisions and Hernia codes), Modifiers, Relative Value Units, and the CMS Conversion
Episode Transcript
PIYUSH SHETH: Hi everyone. It’s a new year with even more changes to medical coding and billing. This is the 13th Episode of Unraveling Medical Coding. Neal is out this week. Our podcast is about 15 minutes long, and ad-free. Most of the episodes are standalone episodes, so you don’t need to listen in any particular order. Just pick the topic you want to learn more about. Keep in mind that as new rules and guidelines for medical coding and billing come about, some of the information in older episodes may become outdated.
Thanks to all of you, our listeners, who support this podcast. If you know anyone who might be interested in improving their documentation and medical coding, please encourage them to listen to this podcast. Also, if you enjoy this podcast, please leave a rating and review for us on Apple podcasts.
Oh, and I can’t resist briefly promoting the 2023 Edition of my book, Coding Solutions – General Surgery. This edition includes the new Evaluation and Management guidelines for Hospital Services, ICD-10 code changes, and CPT code changes, and I’ve tried to stay true to our mission statement, “Improve Documentation, Code Intelligently, and Minimize Audit Risk.” It is the most efficient presentation of coding concepts out there and it is available on Amazon with a price reduction from the 2022 Edition.
So, let’s get started with the 2023 changes. I’m constantly reminded that change in inevitable and this year is no different. There are new ICD10 codes, CPT codes, and of course the E/M guidelines for Hospital Services have been overhauled. And let’s not forget that the Medicare Conversion Factor and RVUs have also changed. If you’ve been surfing the internet, you’ve no doubt seen a lot of information on the new Hospital E/M services guidelines, but almost no one is talking about RVU changes, even though some very interesting changes have been implemented this year. We’ll get to that later in this episode.
The easiest topic to discuss are the ICD10 code changes. In general, Trauma, Gynecology, Orthopedics, and Cardiology have seen the most code changes. The new codes describe in more specificity certain diagnoses. In Trauma for example, there is more specificity for Motorcycle and Electric Bicycle Accidents as well as for Closed Head Injuries. In Gynecology, there is more specificity for Endometriosis. If you are in any of these specialties, make sure to review these changes so that you are using the most specific ICD10 codes on claims.
Moving on to CPT code changes, new Evaluation and Management guidelines for Hospital services went into effect Jan 1st and align with the Medical Decision Making and Time-based coding methodology implemented for Office visits on Jan 1, 2021. The goal is to decrease the burden of documentation for providers. Unfortunately, there are some negative consequences of the new guidelines that I’ve already seen occurring in the clinical setting. The guidelines state that the History and physical exam should be medically appropriate, and the appropriateness is determined by the providers themselves. Furthermore, the AMA has given examples in their publication “Steps Forward - Simplified Outpatient Documentation and Coding.” The following clinical vignette comes directly from this document:
HPI
40 y/o female with diet-controlled diabetes and obesity presents to establish care after moving from another state. No meds. States she had a visit with her old PCP about 6 months ago, and blood work was done at that time. Currently living with her cousin while looking for jobs. She is a single parent to 2 teenagers. She has not found many grocery stores in the neighborhood and is not comfortable with public transportation. She sometimes can borrow a car from her cousin, but mostly uses this for job hunting, or transporting her children to school events. Asks to defer lab testing until her next visit due to possible out-of-pocket costs.
Physical Exam
BP 120/72 P 74 BMI 35.12
Assessment / Plan:
1. Diet-controlled DM. States had labs done 6 mo ago, does not recall last A1c. Will work on transfer of records and defer testing until next visit.
2. Obesity - discussed daily exercise, adding more vegetables to her diet.
3. SDOH - Patient's care may be negatively impacted by food insecurity due to her current lack of income. Based on this, patient will not be able to access healthy foods to manage her diabetes and obesity. Will consult SW for community resources and social support.
The only data in the physical exam are the vital signs and BMI. No mention of any clinical signs of diabetes such as polydipsia, urinary frequency, weakness, neuropathy, or complications of obesity such as sleep apnea. The charge for this visit is a level 4 New Patient. Ask yourself, “Is this type of scant documentation consistent with billing a level 4 visit? Is this really providing good care to patients?”
Here’s another example:
Patient is an 80 y/o male with left lower quadrant pain. CT scan shows acute perforated diverticulitis with free air. Abdomen is diffusely tender. Plan is to proceed to the OR for an emergent laparotomy under general anesthesia.
Technically since acute perforated diverticulitis is an acute problem that poses a threat to life and the plan is emergent major surgery with procedural risks, this could be billed as a level 5 visit. Four sentences for a level 5 code? I know it follows the coding rules, but as a clinician, would you be comfortable with this? A review of systems, past medical, surgical, and family history, medications and allergies, social history, and a reasonably good physical exam is so rich in information that it seems a travesty to not have it.
If you are looking for the official guidelines, they are available on the AMA website.
Keep in mind that the goal was to decrease the burden of documentation, but this can have a negative impact on patient care. It can allow higher billing with minimal documentation. Also, these documentation guidelines don’t align with Joint Commission requirements and may not align with individual institutional Bylaws requirements. Personally, I’m still going to continue to document a History and Physical exam as I’ve always done.
Another clinical documentation pitfall to be aware of with the new guidelines is how you take credit for ordering / reviewing labs. Let’s say that you are a surgeon and admit a patient with a GI bleed. You order daily Hemoglobin-Hematocrit levels for 3 days. On the day of the initial service, you take credit for ordering the test when you are leveling your visit. The next day, your partner sees the patient and reviews the Hemoglobin-Hematocrit level. Unfortunately, he cannot take credit for reviewing the test because you both are considered the same specialty service and his ordering daily tests is as if you had ordered the daily tests. If, however, the Hospitalist admitted the patient and ordered those same daily tests, and you are the surgical consultant, both you and your partner can take credit daily for reviewing the test results. In applying the new guidelines to Hospital inpatients, there are certain nuances that clinicians need to be aware of.
Other Evaluation and Management code changes include the designation of Emergency Room Evaluation code 99281 as an “MD not required code”, similar to how the Office Outpatient code 99211 which also does not require an MD evaluation, deletion of the Hospital inpatient consultation code 99251 similar to the deletion of the Office outpatient consultation code 99241, and deletion of Hospital observation codes: 99217 for discharge, 99220 for initial observation service, and 99224-99226 for subsequent observation care since the “observation” status has been rolled into the “inpatient” status.
My advice: study the guidelines well.
Another major change in CPT codes is in Hernias. Individual codes for Ventral, Incisional, Epigastric, Spigelian, and Umbilical hernias have now been combined into an Anterior Abdominal Wall Hernia section. The new codes are technique independent, meaning that it does not matter whether the hernia was repaired using an open, laparoscopic, or robotic technique. The codes are classified by the total length of the defect or defects, whether it is an initial or recurrent hernia, and if it is a reducible, incarcerated, or strangulated hernia. The total length of the hernia defects is measured as the maximum dimension of an oval drawn to encircle the outer perimeter of all repaired defects. Defects should be measured prior to opening the fascia or from pre-operative imaging tests. If there are multiple fascial defects and they are separated by 10 cm or more of intact fascia, the total defect size is the sum of each defect measured individually and not the size of a large oval drawn around the multiple defects. Of special note is that these new Anterior Abdominal Wall Hernia codes have a 0-day global period. This means that if the patient returns on any day after the day of surgery, that visit is billable. If the patient returns to the office in 1 week for suture removal, that is billable.
There are also new Parastomal hernia codes as well as a new code for removal of mesh.
For 2023, Medicare has set the Conversion factor for the physician fee schedule at 33.06. This is a 4.5% decrease from 2022. It’s also the lowest conversion factor since 1995. I’ll put this into perspective. The Consumer Price Index over the same period went from 150 to 297. An item that cost $150 in 1995 would cost almost $300 now. Coupled with the overall decrease in RVU’s across the board during that time, reimbursement has plummeted. What if your salary remained the same while the cost of living increased by 100%?
The final topic I want to discuss are the RVU changes in 2023. Nobody is talking about this much and I suspect that is because all the other changes have overshadowed this. But in the process of updating my book with new work RVU values, I noticed some interesting changes. The simplest of the work RVU changes are related to new work RVU values for the Anterior Abdominal Wall Hernia Repair CPT codes. Unfortunately, there is no way to benchmark whether the new values are favorable for surgeons or not since they also removed the 90-day global period. Comparing the new values to the previous code values would be like comparing apples to oranges.
Evaluation and Management code work RVUs also have changed. Initial Hospital service work RVUs are down up to 15% but subsequent Hospital service work RVUs are up 14-20%. Office consultation work RVUs are down up to 19% and Hospital consultation work RVUs are down up to 17%. For example, work RVUs for a Hospital inpatient initial service 99222 dropped from 2.61 to 2.60, but the equivalent Hospital consultation service 99254 has dropped from 3.29 to 2.72. To make this simpler to understand, let’s ask the question, how many consult visits would you have to bill to have the equivalent additional work RVU’s amount to one additional new patient visit. In 2022 it was 4, but in 2023 it is 22. What a huge change! In 2023, it is not as advantageous to bill consultation codes as it was in the past especially since using the consultation codes have additional documentation requirements.
No matter how you look at the finances of healthcare, reimbursement for services rendered continue to plummet and I predict the recent change in documentation guidelines will most likely lead to worse patient care as evidenced by removal of standardization in documentation.
I’ll end with a question. When using time-based office outpatient service coding, for any total times between 20 and 54 minutes, established patient visits always have higher work RVUs when compared to new patient visits. For example, a 30-minute office outpatient service translates to 1.92 work RVU for an established patient and 1.60 work RVU for a new patient. Do you think this valuation is correct? Let me know your thoughts by sending me an email at: CodingSolutionsGS@gmail.com.