E/M services on / after January 1, 2023

If the date of service is on / after 1/1/23, select from the following service types:

• Office / outpatient
• Hospital inpatient / observation
• Emergency department services
• Nursing facility services
• Home or residence services

Once the service type is selected, corresponding subcategories will display. Select the subcategory applicable to the E/M services provided.

Here is an example of the subcategory options for "Hospital inpatient / observation" services:

Components for E/M code determination

Depending on the service type and subcategory selected, the E/M code may be determined via time and/or medical decision making (MDM).

Use the presenting illness as a guiding factor and clinical judgment about the patient's condition to determine the extent of service to be performed. The key components of this determination are the medical decision making or total time E/M services are performed.

Time

Time may be documented or recorded as multiple entries that will be aggregated for that date of service or in a free-form manner combining all with a single entry.

Based on information submitted, the worksheet will provide an aggregated summation and corresponding code.

Medical decision making

Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. To qualify for a particular level of medical decision making, two of the three elements for a level of medical decision making must be met or exceeded.

Selections for each element are made, with a level of medical decision making determined by the worksheet, and a corresponding, suggested code displayed. To assist with selections, view details for each level by clicking on the informational icons. In addition, the Helpful Resources icon provides links to resources including the AMA CPT E/M changes for 2023.