New for 2021 and 2023: Evaluation and Management Documentation Guidelines and Code Updates 

Quality & Practice

2023 Changes - Including Inpatient and SNF E/M Codes 

On January 1, 2023, updated code descriptors and documentation guidelines for several evaluation and management (E/M) code sets will take effect.  Most notably for physiatry, this includes hospital inpatient codes, and nursing facility codes.  Updated hospital inpatient codes include initial (99221-23) and subsequent encounters (99231-33).  Updated nursing facility codes include initial (99304-06) subsequent nursing facility encounters (99307-10) as well as discharge management (99315 and 99316).  Revisions were also made to consultation codes, emergency department codes, home or residence service codes, and prolonged services codes. 

As with the office and outpatient E/M changes, this was the result of a multi-year advocacy effort.  AAPM&R was one of the participating societies that contributed to the E/M revisions and revaluation. The new guidelines correspond to similar changes made to the office and outpatient E/M guidelines.  This should remove some confusion for providers who practice in multiple settings. 

Click here for comprehensive information detailing the new 2023 documentation guidelines. 

2021 Changes - Including Office and Outpatient E/M Codes  

On January 1, 2021, code descriptors and documentation guidelines for office and outpatient evaluation and management (E/M) codes changed. This major coding overhaul reflects the most substantial updates to E/M since the mid-1990s.

These changes are the result of a multi-year advocacy effort. AAPM&R was one of the participating societies that contributed to the E/M revisions and revaluation. The new guidelines are expected to reduce documentation burden and make coding selection easier.

Under the new guidelines, code selection is now based on either medical decision making or time. History and physical exam will still be documented, but not a part of the code selection process.

Given the significant nature of these changes, AAPM&R is offering members complimentary access to our 2020 Annual Assembly session on E/M in 2021.

2021 E/M Coding Resources

  • If you registered for AAPM&R's Annual Assembly, be sure to watch E/M in 2021 - Tips and Tricks for Coding and Documentation Under the New Guidelines on-demand.
  • Didn't get a chance to register for #AAPMR20? AAPM&R members can access the E/M in 2021 - Tips and Tricks for Coding and Documentation Under the New Guidelines recording on our Online Learning Portal.

 

Watch the video clips below for a sneak peek at this session: