2023 CPT Guideline Changes

[RustedFox]

Agreed.
Chest pain gets a "High risk possible diagnoses include ACS" in my chart (assuming I'm getting an EKG and a trop, even if it's a 30 yr old and the trop was ordered in triage).
Abd pain getting imaging gets: High risk possible diagnoses include perforated hollow viscous, appendicitis, blah blah blah that you would see on a CT scan so writing it down shouldn't open up much medmal risk

Did I order a cbc and a chem only? You bet I'm either documenting one thing family said, or checking their med fill history or whatever to get that 2nd column up to 3 points of data and thus at least a lvl 4.

Everyone who isn't getting admitted either gets a Rx or gets documentation regarding why I considered, but did not provide an Rx. That gets you a lvl 4 at least in the Risk column.

It's all a stupid game. The only part I don't have solidly down (because our coders have been mum on it) is whether my "high risk" comments above are actually checking the box for a lvl 5 chart in the COPA column as that's ultimately at their discretion. The other two columns are pretty checkbox in nature.

So, as much as I hate MediTECH, our version has a pretty great [autotext/macro/whatever-you-want-to-call-it] for each of these situations and more. I simply put that exact text into a microphone command and boom, I'm done.

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[southerndoc]

I always document a HEART score on all non-traumatic chest pain and put "patient risk stratified for consideration of admission".

 

[thegenius]

Not all chest pain is HIGH complexity, even ACEP says that. Ultimately people can code what they want, although they may not get it. A 35 yo healthy man with chest pain and normal vitals and normal ECG is very doubtful highly complex (or "life threatening") unless you somehow think they are hiding a massive PE or dissection within their chest. Even if you rule out a PE or dissection with a DDimer or thoracic imaging, that adds complexity to the case and may not lead to COPA HIGH. If your chest pain however has ischemia on the EKG, or a BP of 200/100, or hypoxia, or tachycardia, or has multiple comorbidities, or AMS or something else - that can make it high risk. The ACEP FAQ suggests this in a round about way.

I suspect ultimately that insurers will be watching the ratios of all their coded charts carefully. If a ER group had in prior years a ratio like 20% 99283, 40% 99284, and 40% 99285 going back a few years...and now all of a sudden MDs are charting or claiming that it's now 5% 99292, 30% 99284 and 65% 99285, they will call BS and just not give it to you. Patients didn't magically get more sick on Jan 1 2023.

We've got a super aggressive guy in our group who basically charts 99285 on almost all his charts, and will even say lacs to the hand or finger are 99285 as "severe injury threatening body function". I saw the pt a week later to take out the stitches and he showed me a picture of the lac and never had any threat to body function.

I guess the important thing is at least maximizing two of three columns.

 

[Jabbed]

Not all chest pain is HIGH complexity, even ACEP says that. Ultimately people can code what they want, although they may not get it. A 35 yo healthy man with chest pain and normal vitals and normal ECG is very doubtful highly complex (or "life threatening") unless you somehow think they are hiding a massive PE or dissection within their chest. Even if you rule out a PE or dissection with a DDimer or thoracic imaging, that adds complexity to the case and may not lead to COPA HIGH. If your chest pain however has ischemia on the EKG, or a BP of 200/100, or hypoxia, or tachycardia, or has multiple comorbidities, or AMS or something else - that can make it high risk. The ACEP FAQ suggests this in a round about way.

I suspect ultimately that insurers will be watching the ratios of all their coded charts carefully. If a ER group had in prior years a ratio like 20% 99283, 40% 99284, and 40% 99285 going back a few years...and now all of a sudden MDs are charting or claiming that it's now 5% 99292, 30% 99284 and 65% 99285, they will call BS and just not give it to you. Patients didn't magically get more sick on Jan 1 2023.

We've got a super aggressive guy in our group who basically charts 99285 on almost all his charts, and will even say lacs to the hand or finger are 99285 as "severe injury threatening body function". I saw the pt a week later to take out the stitches and he showed me a picture of the lac and never had any threat to body function.

I guess the important thing is at least maximizing two of three columns.

I try not to factor in COPA because of how ambiguously it might be interpreted. I’m not a fan of writing “severe injury threatening bodily function” on my charts either unless it’s a big trauma.

I only focus on the other two columns. Most patients that you admit will be level 5 (MDM complexity: 3 data points + talk to another clinician; Risk of complications: decisions regarding hospitalization).

I only focus on maximizing billing on patients that I’m discharging. I’ll always try to buff up the 3 data points (extra history from EMS or family, old records, considered ordering xyz). I’ll generally try and interpret some sort of imaging, even if it was not done same day. Risk of complications is the grey area. Social determinants or Rx management = easy level 4. Parenteral controlled substances or ‘considered admission’ = level 5.

This is biasing me towards doing IM morphine vs PO meds for things like lumbar radiculopathy, minor fractures, etc. I’ll also document “required continuous telemetry for parenteral administration for QTc prolonging agent” if they get droperidol or haldol as that should also bill out as a level 5.

I tell my midlevels to follow this thought process. If it’s chest pain, belly pain, pregnancy complication, or you ordered CTs/talked to a consultant. Shoot for level 5. Everything else should be at least level 4 imo.

 

[BoardingDoc]

Just got some quick and dirty data about our billing under the new CPT guideline changes.

Lvl 5 chart percentage: Basically unchanged
Lvl 3 charts: almost entirely converted to lvl 4 charts.

Based on the percent of charts that were previously 3s that are now 4s, that should represent a roughly 9% increase in wRVUs for my group as a whole. Even if you take into account the ~2% conversion factor drop from medicare this year (34.6062 --> 33.8872) we are definitely still coming out ahead on this.

I don't have my own personal numbers yet, but I'm tentatively very excited as my own chart spread was significantly heavier on 3s than the group average which would be very lovely if they all became 4s.

 

[thegenius]

@BoardingDoc that is great news. We are kind of seeing the same thing. More 3's going to 4's. However our coder/biller is still giving us way too many 2's, of which there should be just about none. If you make a chart in the ED it's probably < 1% chance it's a 2. Unless the pt is there to "get a new bandaid" or "I'm hungry" or something. We are working with them.

Also finding that suggesting our own coding level is quite helpful and I/we use that link above somewhere in this thread (e.g. Home - ERNotes - ER Charting Made Simple click on "Coding Level Tool").

Overall the charts are easier to read too. No more ROS, Social, exams are only what they should be, etc.

 

[lucid_leprechaun]

@BoardingDoc that is great news. We are kind of seeing the same thing. More 3's going to 4's. However our coder/biller is still giving us way too many 2's, of which there should be just about none. If you make a chart in the ED it's probably < 1% chance it's a 2. Unless the pt is there to "get a new bandaid" or "I'm hungry" or something. We are working with them.

Also finding that suggesting our own coding level is quite helpful and I/we use that link above somewhere in this thread (e.g. Home - ERNotes - ER Charting Made Simple click on "Coding Level Tool").

Overall the charts are easier to read too. No more ROS, Social, exams are only what they should be, etc.

I agree. I think the CMS change has been for the good. We are seeing almost all four and five charts. About the same critical care. I imagine it depends on your billing company

 

[Janders]

@BoardingDoc that is great news. We are kind of seeing the same thing. More 3's going to 4's. However our coder/biller is still giving us way too many 2's, of which there should be just about none. If you make a chart in the ED it's probably < 1% chance it's a 2. Unless the pt is there to "get a new bandaid" or "I'm hungry" or something. We are working with them.

Also finding that suggesting our own coding level is quite helpful and I/we use that link above somewhere in this thread (e.g. Home - ERNotes - ER Charting Made Simple click on "Coding Level Tool").

Overall the charts are easier to read too. No more ROS, Social, exams are only what they should be, etc.

2s! The horror! how does that even happen.

 

[bravotwozero]

Per our CMG, a number of level 5s got downgraded to 4s, but a lot of 3s also got upcoded to 4s, which resulted in a net uptick of RVUs. I personally have not seen any changes in my RVUs under the new payment system.

 

[JacobMcCandles]

Per our CMG, a number of level 5s got downgraded to 4s, but a lot of 3s also got upcoded to 4s, which resulted in a net uptick of RVUs. I personally have not seen any changes in my RVUs under the new payment system.

Not a CMG but we’ve had a similar experience with less 5s but more 4s which equal slightly higher RVUs/patient.

 

[DocEspana]

I'm friendly with the billing director that manages the various hospitals in florida my CMG has its hands on. He says that our level 5s jumped a small amount but our level 4s skyrocketed. Level 3s have plummeted. Also says hes not that worried in the grand scheme of things because our level 2s have also risen quite a bit and he thinks CMS will view that as balancing out. He cant figure out why the level 2s rose, and asked me.

I pointed out that we all began covering a free standing ED earlier this year - where we dont get paid based on RVUs but rather on flat pay. So obviously we all just dont even bother with the MDM except as needed for medicolegal defensibility. Almost certainly that's the majority of our "not worrying" distribution. A bunch of low acuity level 2s that we dont even try with and then all of our RVU-based ED visits being juiced and upcoded to all hell.

 

[Mount Asclepius]

Also says hes not that worried in the grand scheme of things because our level 2s have also risen quite a bit and he thinks CMS will view that as balancing out. He cant figure out why the level 2s rose, and asked me.

I pointed out that we all began covering a free standing ED earlier this year - where we dont get paid based on RVUs but rather on flat pay. So obviously we all just dont even bother with the MDM except as needed for medicolegal defensibility. Almost certainly that's the majority of our "not worrying" distribution. A bunch of low acuity level 2s that we dont even try with and then all of our RVU-based ED visits being juiced and upcoded to all hell.

Real EDs don’t have many level 2s. They should be <1-2%. Otherwise you are running an urgent care, or under billing.

 

[JacobMcCandles]

I'm friendly with the billing director that manages the various hospitals in florida my CMG has its hands on. He says that our level 5s jumped a small amount but our level 4s skyrocketed. Level 3s have plummeted. Also says hes not that worried in the grand scheme of things because our level 2s have also risen quite a bit and he thinks CMS will view that as balancing out. He cant figure out why the level 2s rose, and asked me.

I pointed out that we all began covering a free standing ED earlier this year - where we dont get paid based on RVUs but rather on flat pay. So obviously we all just dont even bother with the MDM except as needed for medicolegal defensibility. Almost certainly that's the majority of our "not worrying" distribution. A bunch of low acuity level 2s that we dont even try with and then all of our RVU-based ED visits being juiced and upcoded to all hell.

I would look to the billing company rather than thinking the docs completely change the way they write notes/practice. It’d have to be an incredibly busy FSED with a large enough sample size and incredibly low acuity (I mean like all med refills with ZERO testing) for it to have that much of an impact. It’s almost difficult to intentionally get a level 2 chart in an acute care setting.

 

[DocEspana]

Real EDs don’t have many level 2s. They should be <1-2%. Otherwise you are running an urgent care, or under billing.

A new freestanding ED is basically an urgent care center with IV access and a never-been-opened crash cart.

 

[DocEspana]

I would look to the billing company rather than thinking the docs completely change the way they write notes/practice. It’d have to be an incredibly busy FSED with a large enough sample size and incredibly low acuity (I mean like all med refills with ZERO testing) for it to have that much of an impact. It’s almost difficult to intentionally get a level 2 chart in an acute care setting.

URIs and UTIs all day every day and no incentive to write much. Think of it this way, how much would you write for those complaints if you didn't get paid to write anything beyond what you truly felt needed to be written from a medico legal perspective. Its not like flat pay at an ED (which I had for a while) where lots of people are medically complex and you need to document a lot - so some of this becomes momentum and you document a lot on the stupid complaints as well.

what if they were all simple complaints?

 

[JacobMcCandles]

URIs and UTIs all day every day and no incentive to write much. Think of it this way, how much would you write for those complaints if you didn't get paid to write anything beyond what you truly felt needed to be written from a medico legal perspective. Its not like flat pay at an ED (which I had for a while) where lots of people are medically complex and you need to document a lot - so some of this becomes momentum and you document a lot on the stupid complaints as well.

what if they were all simple complaints?

Again, a Level 2 is basically a MSE exam where you do absolutely nothing and then purposefully document basically nothing.

We cover multiple EDs that run the gamut from FSEDs to busier higher acuity places and you can count on your fingers and toes the number of Level 2 charts we have. Of course, we see our fair share of UTIs, URIs, etc. Those aren’t Level 2 charts. We have plenty of physicians who document minimally. If you have anything greater than 0.5% of charts as Level 2s, it’s a billing issue. Even the simplest of complaints is a Level 3 in an acute care setting.

 

[DocEspana]

Again, a Level 2 is basically a MSE exam where you do absolutely nothing and then purposefully document basically nothing.

We cover multiple EDs that run the gamut from FSEDs to busier higher acuity places and you can count on your fingers and toes the number of Level 2 charts we have. Of course, we see our fair share of UTIs, URIs, etc. Those aren’t Level 2 charts. We have plenty of physicians who document minimally. If you have anything greater than 0.5% of charts as Level 2s, it’s a billing issue. Even the simplest of complaints is a Level 3 in an acute care setting.

intriguing. youd assume a major cmg wouldnt screw this up.

 

[JacobMcCandles]

intriguing. youd assume a major cmg wouldnt screw this up.

Our billing company is not even what I would consider aggressive. They definitely try to code things appropriately and within the confines of reasonable. I’m surprised you’re surprised on what a CMG could screw up.

 

[DocEspana]

Our billing company is not even what I would consider aggressive. They definitely try to code things appropriately and within the confines of reasonable. I’m surprised you’re surprised on what a CMG could screw up.

I work under the assumption that their billing strategy is "grab the patient by the ankles and shake them until all the coins fall out." So leaving an opportunity unfulfilled did surprise me.

 

[gutonc]

intriguing. youd assume a major cmg wouldnt screw this up.

You might. But I wouldn't.

 

[thegenius]

Real EDs don’t have many level 2s. They should be <1-2%. Otherwise you are running an urgent care, or under billing.

i agree with this, 99292 under new billing guidelines should be non-existent. only bug bites, dressing changes, med refills, suture removal etc.

The problem we have is our biller/coder Optum is just terrible and our billing was even worse in 2023, and we've had to fight tooth and nail for them to resubmit midcoded charts. Optum is so bad

 

[thegenius]

URIs and UTIs all day every day and no incentive to write much. Think of it this way, how much would you write for those complaints if you didn't get paid to write anything beyond what you truly felt needed to be written from a medico legal perspective. Its not like flat pay at an ED (which I had for a while) where lots of people are medically complex and you need to document a lot - so some of this becomes momentum and you document a lot on the stupid complaints as well.

what if they were all simple complaints?

Simple, uncomplicated UTI:
- COPA : "1 acute, uncomplicated illness or injury": Low 3
- DATA: [2 tests ordered (UA, UCx) + review 1 prior tests or note] OR [review 3 prior tests or notes]: Moderate 4
- RISK: drug admin and mgmt (macrobid Rx): Moderate 4

That's a 99284 chart (can review it at 2023 Coding Level Tool to check yourself.)

Just sayin. This is a 2 minute encounter for a pt who gets an Rx for macrobid. 99284

Simple, uncomplicated URI:
- COPA: 1 acute, uncomplicated illness or injury: Low 3
- DATA: [2 tests ordered (Flu / COVID) + review 1 prior test or note, or CXR] OR [review 3 prior tests or notes]: Moderate 4
- RISK: Drug Admin and mgmt (benzonatate Rx, flonase Rx, cepacol Rx, afrin Rx, mucinex Rx, codeine Rx, etc): Moderate 4

That's a 99284 chart.

Check out 2023 Coding Level Tool. The link to the coding level tool for some reason changes from time to time. The webpage is just dope



The fact is, while not always, we often glance and read prior charts and labs when making decisions. Want to know the pt's prior Cr or QT interval? we often look at stuff and just do things out of habit like reconcile pt meds in our head when making decisions and much of this counts towards. And we do these decisions in seconds, not minutes.

 

[thegenius]

Again, a Level 2 is basically a MSE exam where you do absolutely nothing and then purposefully document basically nothing.

We cover multiple EDs that run the gamut from FSEDs to busier higher acuity places and you can count on your fingers and toes the number of Level 2 charts we have. Of course, we see our fair share of UTIs, URIs, etc. Those aren’t Level 2 charts. We have plenty of physicians who document minimally. If you have anything greater than 0.5% of charts as Level 2s, it’s a billing issue. Even the simplest of complaints is a Level 3 in an acute care setting.

100% agree

 

[thegenius]

Ok question:

Under High risk is the notion of "Decision Regarding Hospitalization" This also is a decision about alternate levels of care (being discharged to a SNF or board and care).

Do you think if you discharge a patient with a new order for Home Health to visit and see patient at home that it would qualify for this "Decision Regarding Hospitalization" selection?

 

[BoardingDoc]

Ok question:

Under High risk is the notion of "Decision Regarding Hospitalization" This also is a decision about alternate levels of care (being discharged to a SNF or board and care).

Do you think if you discharge a patient with a new order for Home Health to visit and see patient at home that it would qualify for this "Decision Regarding Hospitalization" selection?

Absolutely yes. If they're going home with services, that means you felt they were unsafe to go home without them. Which means you considered the possibility that they'd be admitted to the floor or to obs for rehab placement as a possibility.

 

[Jabbed]

Ok question:

Under High risk is the notion of "Decision Regarding Hospitalization" This also is a decision about alternate levels of care (being discharged to a SNF or board and care).

Do you think if you discharge a patient with a new order for Home Health to visit and see patient at home that it would qualify for this "Decision Regarding Hospitalization" selection?

I’ve documented this “Considered medical admission, however appropriate outpatient management will be provided through x, y, and z”

I also “consider admission” on patients that are able to get urgent semi-elective procedures done while in the ED (therapeutic paracentesis, PICC replacement, tunneled CVL).

 

[wareagle726]

A new freestanding ED is basically an urgent care center with IV access and a never-been-opened crash cart.

Bet you open that cart on the next shift.

 

[thegenius]

I’ve documented this “Considered medical admission, however appropriate outpatient management will be provided through x, y, and z”

I also “consider admission” on patients that are able to get urgent semi-elective procedures done while in the ED (therapeutic paracentesis, PICC replacement, tunneled CVL).

That's a good one actually (the second one)

 

[BoardingDoc]

I’ve documented this “Considered medical admission, however appropriate outpatient management will be provided through x, y, and z”

I also “consider admission” on patients that are able to get urgent semi-elective procedures done while in the ED (therapeutic paracentesis, PICC replacement, tunneled CVL).

Lol at the differences in resources available. I assume you work in an academic center? Literally every one of the examples you listed as "something you can get done in the ED and then DC" would have to be admitted in my shop. I suppose I could do the therapeutic para myself, but I generally don't have time for that.

 

[Jabbed]

Lol at the differences in resources available. I assume you work in an academic center? Literally every one of the examples you listed as "something you can get done in the ED and then DC" would have to be admitted in my shop. I suppose I could do the therapeutic para myself, but I generally don't have time for that.

Community site with county population. Think the nicer part of Skidrow. We just have in-house IR midlevels during business hours so we can occasionally get these things done in the ED. Others they get admitted/obs unit.

 

[thegenius]

Community site with county population. Think the nicer part of Skidrow. We just have in-house IR midlevels during business hours so we can occasionally get these things done in the ED. Others they get admitted/obs unit.

Depending on what the procedure is, you can also get a High RISK. Like if you are doing a para. Not sure if an LP is a major procedure or not. the AMA and ACEP doesn't put too much guidance on that.

 

[wareagle726]

Depending on what the procedure is, you can also get a High RISK. Like if you are doing a para. Not sure if an LP is a major procedure or not. the AMA and ACEP doesn't put too much guidance on that.

FWIW I've been putting LPs as "high risk" procedure due to risk for CNS infection and nerve damage. Also, if I'm doing an LP they are probably getting a high COPA, at least a moderate(probably high) data, and definitely considering admission so it's really a moot point in the "risk" column.

 

[southerndoc]

LPs are done to rule out life threatening presentations or those with severe threats to bodily function. Most of us also do a CT head prior to doing this. Order 2 labs, order a head CT and look at it, and you're at a level 5 right there.

People often don't put enough emphasis on potentially life-threatening. Yes, that chest pain may be reproducible upon palpation, but the ultimate diagnosis of costochondritis isn't what determines if it's life-threatening or not. It's the presentation to the layperson. A young chest pain still has the same differential: TAD, PTX, pneumomediastinum, PE, etc. Those are life-threatening. You can rule them out by saying you don't believe it's TAD because x,y,z but that doesn't reduce the severity of their presentation.

 

[Jabbed]

LPs are done to rule out life threatening presentations or those with severe threats to bodily function. Most of us also do a CT head prior to doing this. Order 2 labs, order a head CT and look at it, and you're at a level 5 right there.

People often don't put enough emphasis on potentially life-threatening. Yes, that chest pain may be reproducible upon palpation, but the ultimate diagnosis of costochondritis isn't what determines if it's life-threatening or not. It's the presentation to the layperson. A young chest pain still has the same differential: TAD, PTX, pneumomediastinum, PE, etc. Those are life-threatening. You can rule them out by saying you don't believe it's TAD because x,y,z but that doesn't reduce the severity of their presentation.

Ironic, because young person with benign atypical chest pain was anticipated to be one of the prime targets for CMS down-coding.

But if we’re playing the “anything can be anything” game then literally any complaint can be upcoded to a level 5.

-Penile discharge: “could be Fournier’s!”
-Med refill: “might have a hypertensive crisis without their lisinopril!”
-Homeless foot pain: “I considered limb ischemia, but foot was warm and well-perfused and symptoms improved after Turkey sandwich”

And therein lies the audit.

 

[thegenius]

Ironic, because young person with benign atypical chest pain was anticipated to be one of the prime targets for CMS down-coding.

But if we’re playing the “anything can be anything” game then literally any complaint can be upcoded to a level 5.

-Penile discharge: “could be Fournier’s!”
-Med refill: “might have a hypertensive crisis without their lisinopril!”
-Homeless foot pain: “I considered limb ischemia, but foot was warm and well-perfused and symptoms improved after Turkey sandwich”

And therein lies the audit.

ACEP even guides us that chest pain is a COPA 4, however some select presentations of chest pain (e.g. cardiac ischemia) is a 5. I agree not everything can be a COPA 5. So yea not every chest pain can be max complexity. I would suggest chest pain in the elderly is prob a 5, chest pain with a million risk factors, or chest pain with abnormal vitals or an abnormal EKG.

 

[Mount Asclepius]

Every chest pain should be a 5. Pay us for our work. I’m willing to consider allowing some cases to be 4s if you remove our medicolegal liability for missed diagnoses and don’t set the standard of care miss rate at <1%.

 

[TooMuchResearch]

ACEP even guides us that chest pain is a COPA 4, however some select presentations of chest pain (e.g. cardiac ischemia) is a 5. I agree not everything can be a COPA 5. So yea not every chest pain can be max complexity. I would suggest chest pain in the elderly is prob a 5, chest pain with a million risk factors, or chest pain with abnormal vitals or an abnormal EKG.

I'll take 99284 in 18 year olds with chest pain only if I can stop getting ECG, trop, and imaging in them. Until then, I think I should get paid for the work.