Regulation Changes for Billing in 2023

Regulatory compliance helps you protect your business's resources and reputation. Building trust with prospects, customers, and vendors takes time. A large part of that depends on your ethical conduct. Compliance is the foundation upon which your company's reputation can be built. For those who work in the midwifery industry, the sheer number of regulations that regulate maternity care can be overwhelming. Nearly every aspect of this is monitored by one or more regulatory bodies. Some midwives feel they spend more time following rules than actually performing the work. 
Billing is a complicated part of your midwifery practice because its system is designed to allow for payment by insurance companies or government programs like Medicare and Medicaid. These payers require that bills be submitted using specific diagnosis, treatment, and supply codes. Otherwise, the bills will not get paid. That is why you need to be aware of any changes in billing regulations, regardless of whether you bill for your own practice or hire someone. New billing regulations have been published since the end of the year. These are the new billing regulations that every customer and biller must know about for 2023.

• The American Medical Association (AMA) has released CPT® Evaluation and Management (E/M) Code and Guideline Changes that will go into effect January 1, 2023

Evaluation and Management (E/M) services include office visits, hospital visits, home services, and preventive medicine services. Understanding how to properly document and code these high-volume services is important as even small mistakes in E/M coding can result in major compliance and payment issues. The updated E/M guidelines for 2023 aim to simplify and streamline coding and documentation for E/M services and are being welcomed by physicians and providers of medical billing and coding services.

The existing 2021 guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) allow healthcare providers to document E/M visits based on medical decision-making (MDM) or total time. This was a major departure from the previous guidelines that required them to address three elements in the patient’s progress notes: patient history, physical exam and medical decision making for code selection). The new E/M guidelines for 2023 build on the flexibilities of the 2021 office/outpatient E/M coding and documentation rules.

2023 E/M Code Updates Reduce Documentation Burden
The goal of the updated guidelines for coding and documenting E/M services is to make coding and documenting E/M services easier for medical practices and other facilities.

• Level of E/M services will be based on the following:
  • The level of the MDM as defined for each service

OR

• Time spent by the practitioner includes face-to-face and non-face-to-face time

• History and exam no longer used to select the level of code

• Hospital Observation Services E/M codes deleted and inpatient Hospital Services E/M codes revised to include Observation Care Services:
  • Hospital observation CPT codes (99217-99220 and 99224- 99226) have been deleted and merged into the existing hospital care CPT codes (99221-99223, 99221-99233, and 99238-99239)
  • The code descriptors have been revised to account for the structure of total time on the date of the encounter or level of medical decision-making when selecting code level
  • Retention of revised observation or inpatient care services, including admission and discharge services (CPT codes 99234 through 99236)

• Consultations:
  • Consultation codes retained with some revisions to the code descriptors
  • Certain guidelines deemed confusing by the AMA have been deleted, including the definition of “transfer of care”
  • Lowest level office (99241) and inpatient (99251) consultation codes have been deleted to align with four levels of MDM

• Revision of Emergency Department Services E/M codes 99281-99285 and guidelines:
  • Retention of the existing guideline that time cannot be used as a key criterion for code level selection
  • Revisions to the code descriptors to reflect the code structure approved in the office visit revisions
  • Modification of medical decision making (MDM) levels to align with office visits and maintain exclusive MDM levels for each visit
  • Critical care allowed to be reported in addition to ED service for clinical change
• Home or residence services
  • Revision of Home or Residence Services E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines
  • Domiciliary or rest home CPT codes (99334 through 99340) are deleted and have been merged with the existing home visit CPT codes (99341-99350)
  • When selecting code level using time, do not count any travel time
  • Home or Residence Services E/M code 99343 is deleted
• Prolonged Services Codes
  • Direct patient contact prolonged service codes (99354-99357) are deleted and these services will be reported using code 99417 (office prolonged service), or 993X0, the new inpatient or observation or nursing facility service code
  • New code 993X0 to be analogous to the office visit prolonged services code 99417
  • Codes 99358 and 99359 retained and used when a prolonged service is provided on a date other than the date of a face-to-face evaluation and management encounter with the patient and/or family/caregiver

The 2023 CPT code set also includes a new appendix with a taxonomy that provides guidance for classifying AI-power medical service applications, including expert systems, machine learning, or algorithm-based solutions. There are also new codes to account for emerging virtual care technology and remote monitoring service use in therapy.

1. CMS Issues 2023 Medicare Physician Fee Schedule Final Rule

The Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (PFS) Proposed Rule on Nov. 1, 2022, which impacts Medicare Part B payments starting on Jan. 1, 2023.
The final CY 2023 PFS conversion factor is $33.06, a 4.48 percent decrease from CY 2022 and slightly higher than proposed. This decline is due to a statutorily required budget neutrality adjustment, an expiring temporary adjustment to mitigate the impact of previous coding changes and a zero percent update factor.
CMS finalized several significant payment policy changes, including revaluing remaining evaluation and management codes, continuing its four-year phase-in of clinical labor pricing updates, and delaying changes to redefine the substantive portion of a split/shared visit by time only until 2024.

References

CMS issues 2023 Medicare physician fee schedule final rule: Insights. Holland & Knight. (n.d.). Retrieved November 28, 2022, from https://www.hklaw.com/en/insights/publications/2022/11/cms-issues-2023-medicare-physician-fee-schedule-final-rule 
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What are the latest medical billing and coding changes in 2022? Outsource Strategies International. (2022, November 7). Retrieved November 28, 2022, from https://www.outsourcestrategies.com/blog/what-are-latest-medical-billing-and-coding-changes-in-2022/