cpt code for er visit level 1

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Emergency CPT – 99283, 99284, 99285, 99281, 99282

by Medical Billing | Jan 9, 2013 | CPT modifiers | 1 comment

99283 (CPT G0382) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.

99284 (CPT G0383) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. average fee payment – $110 – $120 Moderate-High Complexity (99284/G0383): The presented problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration.

99285 (G0384) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. average fee amount – $170 – $180

99288 Physician direction of emergency medical systems (EMS) emergency care, advanced life support Billing and Coding Guidelines. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 93005 (Twelve lead ECG) Example #2: A patient is seen in the ED after a fall. Lacerations sustained from the fall are repaired and radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 12001-13160 (Repair/Closure of the Laceration) 70010-79900 (Radiological X-ray) Example #3: A patient is seen in the ED after a fall, complaining of shoulder pain. Radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 70010-79900 (Radiological X-ray) NOTE: Using example #3 above, if a subsequent ED visit is made on the same date, but no further procedures are performed, appending modifier –25 to that subsequent ED E/M code is NOT appropriate. However, in this instance, since there are two ED E/M visits to the same revenue center (45X), condition code G0 (zero) must be reported in form locator 24 or the corresponding electronic version of the UB92. Per CPT definition, the codes 99281-99285 are for reporting evaluation and management services in the emergency department. An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day. Based on this definition, codes 99281-99285 will be denied provider liable as incompatible if submitted with any place of service (POS) other than 23.

If my patient is registered in the emergency department and I am asked to see him/her, may I submit the emergency service? Answer: Yes. Any physician seeing a patient registered in the emergency department (ED) may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the ED. If the patient is admitted by this provider, the initial hospital service (CPT codes 99221-99223) with the AI HCPCS modifier would be submitted instead of the ED visit codes. Please keep in mind the service must be medically necessary and the documentation must meet the level of complexity of the service rendered. The following guidelines apply to the ED CPT codes 99281 through 99285 billing: ED service is provided to the patient by both the patient’s personal physician and ED physician. If the ED physician, based on the advice of the patient’s personal physician who came to the ED to see the patient, sends the patient home, then the ED physician should bill the appropriate level of ED service. The patient’s personal physician should also bill the level of ED code that describes the service he or she provided in the ED. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient’s personal physician may not bill. If the ED physician requests that another physician evaluate a given patient, the other physician should bill an ED visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he/she should bill an initial hospital care code and not an ED visit code. Overuse and Misuse of CPT Code 99285 The Arizona Healthcare Cost Containment System’s (AHCCCS) Claims Medical Review Unit has noted an increased use of CPT code 99285 on claims for billed emergency room visits. When submitting a claim using CPT code 99285, please document the following: • Comprehensive history • Comprehensive examination • Medical decision for services involving high complexity conditions. Usually the presenting problem(s) are of high severity, are a potential life threatening problem and require the immediate attention of the physician. Services for constipation, earaches and colds, for example, should not be billed using CPT code 99285. AHCCCS will refer any improper billing trends to the Office of the Inspector General.

CPT Code 99285 Emergency Department Visit: Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: • Comprehensive history • Comprehensive examination • Medical decision making of HIGH complexity Comprehensive History: • Reason for admission • Problem pertinent review of systems • Extended history of present illness (HPI) – Includes 4 or more elements of the HPI or the status of at least three chronic or inactive conditions • Review of systems directly related to the problem(s) identified in the HPI • Medically necessary review of ALL body systems’ history • Medically necessary complete past, family, and social history HPI – History of Present Illness: A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include: • Location • Quality • Severity • Timing • Context • Modifying factors • Associated signs/symptoms significantly related to the presenting problem(s) Chief Complaint: The Chief Complaint is a concise statement from the patient describing: • The symptom • Problem • Condition • Diagnosis • Physician recommended return, or other factor that is the reason for the encounter Review of Systems: An inventory of body systems obtained through a series if questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purpose of Review of Systems the following systems are recognized: • Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic Past, Family, and/or Social History (PFSH): Consists of a review of the following: • Past history (patient’s past experiences with illnesses, operations, injuries, and treatments • Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk) • Social History (an age appropriate review of past and current activities Additional Information: • Medicare Providers are responsible for assuring that visits are coded accurately; the unique provider number used when a service is billed ensures that the provider has reviewed and authenticated the accuracy of everything on the submitted claim. • Clearly document your clinical perception of the patient’s condition to assure claims are submitted with the correct level of service. • Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making. • Practitioner’s choosing to use time as the determining factor: – MUST document time in the patient’s medical record – Documentation MUST support in sufficient detail the nature of the counseling – Code selection based on total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection Coding Guidelines Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” Exceptions to Modifier 59 Override: The Health Plan has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending modifier 59 to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement (See also our Screening Services with Evaluation & Management Services and our Bundled Services and Supplies reimbursement policies.): • Duplicate coding • Services and supplies specified in the Bundled Services and Supplies Policy • E/M or DME item codes • National Correct Coding Initiative (NCCI) edit code pairs with a ‘superscript’ of zero, or a modifier allowance indicator of zero. • In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples: 700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (These code ranges include all applicable radiology interpretation codes, as well as radiology codes with modifier 26) reported with 99221-99233 and 99281-99285* 93010, 93018, 93042, 93303, 93307-93308, 93312-93318, 93320-93321, 93325, 93350-93352, and 0180T reported with 99281-99285 Modifier 25 Guidelines 1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25. 2. Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are: 99201-99215 (Office or Outpatient Services) 99281-99285 (Emergency Department Services) 99291 (Critical Care Services) 99241-99245 (Office or Other Outpatient Consultations) NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to “physician” are to be disregarded. Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon. The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier –25 appended should be reported to indicate that the afternoon hypertension clinic visit was not related to the pulmonary function testing. 3. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 93005 (Twelve lead ECG) 045X 99281-99285, 99291 Emergency visit hospital billing UB 04 *Revenue codes have not been identified for these procedures, as they can be performedin a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360), or clinic (0510). Hospitals are to report these HCPCS codes under the revenue center where they were performed. EXAMPLE 1 If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, two separate bills may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to OPPS. In this situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit. EXAMPLE 2 If a patient was seen in the emergency room (ER) and the same patient received nonpartial hospitalization psychological services on the same day as well as several other days in the month, the provider should report the ER visit on the monthly repetitive claim along with the psychological services, since both services are paid under OPPS. Days after the date covered services ended, such as noncovered level of care, or emergency services after the emergency has ended in nonparticipating institutions; • Days for which no Part A payment can be made because the patient was on a leave of absence and was not in the hospital. • Days for which no Part A payment can be made because a hospital whose provider agreement has terminated, expired, or been cancelled may be paid only for covered inpatient services during the limited period following such termination, expiration, or cancellation. All days after the expiration of the period are noncovered. See Chapter 3 for determining the effective date of the limited period and for billing for Part B services; and • Days after the time limit when utilization is not chargeable because the beneficiary is at fault. FL 19 – Type of Admission/Visit Required on inpatient bills only. This is the code indicating priority of this admission. Code Structure: 1 Emergency – The patient required immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient was admitted through the emergency room. 2 Urgent- The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available, suitable accommodation. 3 Elective – The patient’s condition permitted adequate time to schedule the availability of a suitable accommodation. FL 20 – Source of Admission Required For Inpatient Hospital. The provider enters the code indicating the source of this admission or outpatient registration. Code Structure (For Emergency, Elective, or Other Type of Admission): 1 Physician Referral Inpatient: The patient was admitted to this facility upon the recommendation of their personal physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by their personal physician or the patient independently requested outpatient services (self-referral). 2 Clinic Referral Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s clinic physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by this facility’s clinic or other outpatient department physician. 3 HMO Referral Inpatient: The patient was admitted to this facility upon the recommendation of a HMO physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a HMO physician. 4 Transfer from a Hospital Inpatient: The patient was admitted to this facility as a transfer from an acute care facility where they were an inpatient Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another acute care facility. 5 Transfer from a SNF Inpatient: The patient was admitted to this facility as a transfer from a SNF where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where they are an inpatient. 6 Transfer from Another Health Care Facility Inpatient: The patient was admitted to this facility from a health care facility other than an acute care facility or SNF. This includes transfers from nursing homes, long term care facilities and SNF patients that are at a nonskilled level of care. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where they are an inpatient. 7 Emergency Room Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s emergency room physician. Outpatient: The patient received services in this facility’s emergency department. 8 Court/Law Enforcement Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. Outpatient: The patient was referred to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services. 9 Information Not Available Inpatient: The means by which the patient was admitted to this facility is not known. Outpatient: For Medicare outpatient bills, this is not a valid code. A Transfer from a Critical Access Hospital (CAH) Inpatient: The patient was admitted to this facility as a transfer from a CAH where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient. Code Title Definition 44 Inpatient Admission Changed to Outpatient For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. Effective April 1, 2004 45 Reserved for national assignment 46 Non-Availability Statement on File A nonavailability statement must be issued for each TRICARE claim for nonemergency inpatient care when the TRICARE beneficiary resides within the catchment area (usually a 40-mile radius) of a Uniformed Services Hospital. 47 Reserved for TRICARE Code Title Definition 59 Non-primary ESRD Facility Code indicates that ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility. 60 Operating Cost Day Outlier Day Outlier obsolete after FY 1997. (Not reported by providers, not used for a capital day outlier.) PRICER indicates this bill is a length-of-stay outlier. The FI indicates the cost outlier portion paid value code 17. AM Non-emergency Medically Necessary Stretcher Transport Required For ambulance claims. Non-emergency medically necessary stretcher transport required. Effective 10/16/03 AN Preadmission Screening Not Required Person meets the criteria for an exemption from preadmission screening. Effective 1/1/04 G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0. Code Title Definition A4 Covered Self-Administrable Drugs – Emergency The amount included in covered charges for self-administrable drugs administered to the patient in an emergency situation. (The only covered Medicare charges for an ordinarily noncovered, selfadministered drug are for insulin administered to a patient in a diabetic coma. 045X Emergency Room Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care. Rationale: Permits identification of particular items for payers. Under the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital with an emergency department must provide, upon request and within the capabilities of the hospital, an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual’s eligibility for Medicare (Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985). Subcategory Standard Abbreviations 0 – General Classification EMERG ROOM 1 – EMTALA Emergency Medical screening services ER/EMTALA 2 – ER Beyond EMTALA Screening ER/BEYOND EMTALA 6 – Urgent Care URGENT CARE 9 – Other Emergency Room OTHER EMER ROOM 051X Clinic Clinic (nonemergency/scheduled outpatient visit) charges for providing diagnostic, preventive, curative, rehabilitative, and education services to ambulatory patients.Rationale: Provides a breakdown of some clinics that hospitals or third party payers may require. Subcategory Standard Abbreviations 0 – General Classification CLINIC 1 – Chronic Pain Center CHRONIC PAIN CL 2 – Dental Clinic DENTAL CLINIC 3 – Psychiatric Clinic PSYCH CLINIC Usage Notes: 1. To be used by trauma center/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. 2. Revenue Category 068X is used for patients for whom a trauma activation occurred. A trauma team activation/response is a “Notification of key hospital personnel in response to triage information from pre-hospital caregivers in advance of the patient’s arrival.” 3. Revenue Category 068X is for reporting trauma activation costs only. It is an activation fee and not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will normally be both a 045X and 068X revenue code reported. 4. Revenue Category 068X is not limited to admitted patients. 5. Revenue Category 068X must be used in conjunction with FL 19 Type of Admission/Visit code 05 (“Trauma Center”), however FL 19 Code 05 can be used alone. 098X Professional Fees – Extension of 096X & 097X Subcategory Standard Abbreviations 1 – Emergency Room PRO FEE/ER 2 – Outpatient Services PRO FEE/OUTPT 3 – Clinic PRO FEE/CLINIC 4 – Medical Social Services PRO FEE/SOC SVC 5 – EKG PRO FEE/EKG 6 – EEG PRO FEE/EEG 7 – Hospital Visit PRO FEE/HOS VIS 8 – Consultation PRO FEE/CONSULT 9 – Private Duty Nurse FEE/PVT NURSE • Accommodations – 0100s – 0150s, 0200s, 0210s (days) • Blood pints – 0380s (pints) • DME – 0290s (rental months) • Emergency room – 0450, 0452, and 0459 (HCPCS code definition for visit or procedure) • Clinic – 0510s and 0520s (HCPCS code definition for visit or procedure) • Dialysis treatments – 0800s (sessions or days) • Orthotic/prosthetic devices – 0274 (items) • Outpatient therapy visits – 0410, 0420, 0430, 0440, 0480, 0900, and 0943 (Units are equal to the number of times the procedure/service being reported was performed.) • Outpatient clinical diagnostic laboratory tests – 030X-031X (tests) • Radiology – 032x, 034x, 035x, 040x, 061x, and 0333 (HCPCS code definition of tests or services) • Oxygen – 0600s (rental months, feet, or pounds) • Drugs and Biologicals- 0636 (including hemophilia clotting factors) If the patient is self-referred (e.g., emergency room or clinic visit), the provider enters SLF000 in the first six positions, and does not enter a name FL19 – Type of Admission a. One numeric position. b. Required only if the type of bill is 11X or 41X. c. Valid codes are: 1 Emergency 2 Urgent 3 Elective 9 Information unavailable c. Valid codes are: 1. Physician referral 2. Clinic referral 3. HMO referral 4. Transfer from a hospital 5. Transfer from a SNF 6. Transfer from another health care facility 7. Emergency room 8. Court/Law enforcement 9. Information not available A. Inpatient – Patient admitted to this facility as an inpatient transfer from a CAH. Outpatient – Patient referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH where the patient is an inpatient. B. Patient admitted to this HHA as a transfer from another HHA. C. Patient readmitted to this HHA within the same home health episode period.

Reimbursement for emergency inpatient hospital services is permitted only for those periods during which the patient’s state of injury or disease is such that a health or life-endangering emergency existed and continued to exist, requiring immediate care that could be provided only in a hospital. The allegation that an emergency existed must be substantiated by sufficient medical information from the physician or hospital. If the physician’s statement does not provide it, or is not supplemented by adequate clinical corroboration of this allegation, it does not constitute sufficient evidence. Death of the patient does not necessarily establish the existence of a medical emergency, since in some chronic, terminal illnesses, time is available to plan admission to a participating hospital. The lack of adequate care at home or lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission, without an immediate threat to the life and health of the patient. Since the existence of medical necessity for emergency services is based upon the physician’s assessment of the patient prior to admission, serious medical conditions developing after a non-emergency admission are not “emergencies” under the emergency services provisions of the Act. The emergency ceases when it becomes safe, from a medical standpoint, to move the individual to a participating hospital, another institution, or to discharge the individual. Emergency Medical Condition Federal Medicaid regulations define an emergency medical condition (including emergency labor and delivery) as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to: ** Place the person’s health in serious jeopardy; or ** Cause serious impairment to bodily functions; or ** Cause serious dysfunction of any bodily organ or part.

B. Criteria Since the decision that a medical emergency existed can be a matter of subjective medical judgment involving the entire gamut of disease and accident situations, it is impossible to provide arbitrary guidelines. 1. Diagnosis is Considered “Usually an Emergency” An emergency condition is an unanticipated deterioration of a beneficiary’s health which requires the immediate provision of inpatient hospital services because the patient’s chances of survival, or regaining prior health status, depends upon the speed with which medical or surgical procedures are, or can be, applied. While many diagnoses (e.g., myocardial infarction, acute appendicitis) are normally considered emergencies, the hospital must check medical documentation for internal consistencies (e.g., signs and symptoms upon admission, notations concerning changes in a preexisting condition, results of diagnostic tests). EXAMPLE: If the diagnosis is given as “coronary,” the physician’s statement is “coronary,” without further explanatory remarks, and the statement of services rendered gives no indication that an electrocardiogram was taken, or that the patient required intensive care, etc., further information is required. On the other hand, if the diagnosis is one that ordinarily indicates a medical and/or surgical emergency, and the treatment, diagnostic procedures, and period of hospitalization are consistent with the diagnosis, further documentation may be unnecessary. An example is: admitting diagnosis – appendicitis; discharge diagnosis – appendicitis; surgical procedures – appendectomy; period of inpatient stay – 7 days. 2. Patient Dies During Hospitalization If an emergency existed at the time of admission and the patient subsequently expires, the claim is allowed for emergency services if the period of coverage is reasonable. However, death of the patient is not prima facie evidence that an emergency existed; e.g., death can occur as a result of elective surgery or in the case of a chronically ill patient who has a long terminal hospitalization. Such claims are denied. 3. Patient’s Physician Does Not Have Staff Privileges at a Participating Hospital The fact that the beneficiary’s attending physician does not have staff privileges at a participating hospital has no bearing on the emergency services determination. If the lack of staff privileges in an accessible participating hospital is the governing factor in the decision to admit the beneficiary to an “emergency hospital,” the claim is denied irrespective of the seriousness of the medical situation. 4. Beneficiary Chooses to be Admitted to a Nonparticipating Hospital The claim is denied if the beneficiary chooses to be admitted to a non-participating hospital as a personal preference (e.g., participating hospital is on the other side of town) when a bed for the required service is available in an accessible, participating hospital. 5. Beneficiary Cannot be Cared for Adequately at Home The patient who cannot be cared for adequately at home does not necessarily require emergency services. The claim is denied in the absence of an injury, the appearance of a disease or disorder, or an acute change in a pre-existing disease state which poses an immediate threat to the life or health of the individual and which necessitates the use of the most accessible hospital equipped to furnish emergency services. 6. Lack of Suitable Transportation to a Participating Hospital Lack of transportation to a participating hospital does not, in and of itself, constitute a reason for emergency services. The availability of suitable transportation can be considered only when the beneficiary’s medical condition contraindicates taking the time to arrange transportation to a participating hospital. The claim is denied if there is no immediate threat to the life or health of the individual, and time could have been taken to arrange transportation to a participating hospital. 7. “Emergency Condition” Develops Subsequent to a Non-emergency Admission to a Nonparticipating Hospital Program payment cannot be made for emergency services furnished by a nonparticipating hospital when the emergency condition arises after a non-emergency admission. An example: treatment of postoperative complications following an elective surgical procedure or treatment of a myocardial infarction that occurred during a hospitalization for an elective surgical procedure. The existence of medical necessity for emergency services is based upon the physician’s initial assessment of the apparent condition of the patient at the time of the patient’s arrival at the hospital, i.e., prior to admission. 8. Additional “Emergency Condition” Develops Subsequent to an Emergency Admission to a Nonparticipating Hospital If the patient enters a nonparticipating hospital under an emergency situation and subsequently has other injuries, diseases or disorders, or acute changes in preexisting disease conditions, related or unrelated to the condition for which the patient entered, which pose an immediate threat to life or health, emergency services coverage continues. Emergency services coverage ends when it becomes safe from a medical standpoint to move the patient to an available bed in a participating institution or to discharge the patient, whichever occurs first. Emergency Medical Condition An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If you didn’t get immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would have serious damage to any part or organ of your body. Emergency Medical Transportation Ambulance services for an emergency medical condition. Types of emergency medical transportation may include transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or may pay less for certain types. Emergency Room Care / Emergency Services Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions. Urgent Care Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. MISUTILIZATION OF EMERGENCY DEPARTMENT SERVICES Criteria include, but are not limited to, the following: ** More than three emergency department visits in one quarter. ** Repeated emergency department visits with no follow-up with a primary care provider (PCP) or specialist when appropriate. ** More than one outpatient hospital emergency department facility in one quarter. ** Repeated emergency department visits for non-emergent conditions. Emergency Department Visits (Codes 99281 – 99288) A.Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department. B.Use of Emergency Department Codes In Office Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. C.Use of Emergency Department Codes to Bill Nonemergency Services Services in the emergency department may not be emergencies. However the codes (99281 – 99288) are payable if the described services are provided. However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician’s office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition. D.Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment for initial nursing facility care when performed on the same date as the nursing facility admission. E.Physician Billing for Emergency Department Services Provided to Patient by Both Patient’s Personal Physician and Emergency Department Physician If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physicians should bill as follows: *If the patient is admitted to the hospital by the patient’s personal physician, then the patient’s regular physician should bill only the appropriate level of the initial hospital care (codes 99221 – 99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes. *If the ED physician, based on the advice of the patient’s personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient’s personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient’s personal physician may not bill. F.Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Reimbursement Information:BCBS guidelines

The patient’s medical record documentation for diagnosis and treatment in the Emergency Department (ED) must indicate the presenting symptoms, diagnoses and treatment plan and a written order by the physician should be clearly documented in the medical record. Medical records and itemized bills may be requested from the provider to support the level of care that is rendered. Medical records will be used to determine the extent of history, extent of examination performed, complexity of medical decision making (number of diagnoses or management options, amount and/or complexity of data to be reviewed and risk of complications and/or morbidity or mortality) and services rendered. This information will be reviewed in conjunction with the level of care billed and evaluated for appropriateness.

Applicable service codes: Revenue code 450 and/or one of the following procedure codes 99281, 99282, 99283, 99284, 99285, 99288, 99291, 99292, G0380, G0381, G0382, G0383, and G0384.

If observation services are billed with any of the ER associated Evaluation and Management codes, MCG Criteria will be used to evaluate the medical necessity of these observation hours.

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the Clinical Payment and Coding Policy criteria listed below. The ED provides services to patients who are there for immediate medical attention. The physician or other qualified healthcare professional level of service is determined by the following:

1. Straight Forward Complexity (99281/G0380):

The presented problem(s) are self-limited or minor conditions with no medications or home treatment required.

Emergency department visit for the evaluation and management of a patient, which requires these

3 key components:

1) A problem focused history; 2) A problem focused examination; and 3) Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor.

2. Low Complexity (99282/G0381):

The presented problem(s) are of low to moderate severity. Over the counter (OTC) medications or treatment, simple dressing changes; patient demonstrates understanding quickly and easily. Emergency department visit for the evaluation and management of a patient, which requires these

1) An expanded problem focused history; 2) An expanded problem focused examination; and 3) Medical decision making of low complexity.

3. Moderate Complexity (99283/G0382):

The presented problem(s) are of moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

1) An expanded problem focused history; 2) An expanded problem focused examination; and 3) Medical decision making of moderate complexity.

4. Moderate-High Complexity (99284/G0383): Usually, the presented problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

1) A detailed history; 2) A detailed examination; and 3) Medical decision making of moderate complexity.

5. High Complexity (99285/G0384):

The presented problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status:

1) A comprehensive history; 2) A comprehensive examination; and 3) Medical decision making of high complexity.

6. Physician direction of Emergency Medical Systems (EMS) emergency care, advanced life support. (99288)

7. Critical Care (99291) & 99292

The assignment of the Critical Care code 99291 likewise follows the same instructions applicable to the six E&M codes listed above. There is a 30 minute time requirement for facility billing of critical care. The first 30-74 minutes equal code 99291. Any additional 30 minute increments beyond the first 74 minutes is coded 99292.

IV CPT 99284

Type A: APC 615 Type B: APC 629 HCPCS: G0383

Could include interventions from previous levels, plus any of: Preparation for 2 diagnostic tests: (Labs, EKG, X-ray) Prep for plain X-ray (multiple body areas):

C-spine & foot, shoulder & pelvis Prep for special imaging study (CT, MRI, Ultrasound,VQ scans) Cardiac Monitoring (2) Nebulizer treatments

Port-a-cath venous access

Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEG Tube Placement/Replacement Multiple reassessments Prep or assist w/procedures such as: eye irrigation with Morgan lens, bladder irrigation with 3-way foley, pelvic exam, etc.

Sexual Assault Exam w/ out specimen collection Psychotic patient; not suicidal

Discussion of Discharge Instructions (Complex) Blunt/ penetrating trauma- with limited diagnostic testing Headache with nausea/

vomiting Dehydration requiring treatment

Vomiting requiring treatment

Dyspnea requiring oxygen Respiratory illness relieved with (2) nebulizer treatments

Chest Pain–with limited diagnostic testing Abdominal Pain – with limited diagnostic testing

Non-menstrual vaginal bleeding Neurologic symptoms – with limited diagnostic testing V

Type A: APC 616 Could include interventions from previous levels, plus any of:

Requires frequent monitoring of multiple vital signs (i.e. 02 sat, BP, cardiac rhythm, respiratory rate) Preparation for = 3 diagnostic tests: (Labs, EKG, X-ray) Prep for special imaging study (CT, MRI, Ultrasound, VQ Blunt/ penetrating trauma requiring multiple diagnostic tests Systemic multi-system medical emergency requiring multiple Medicare payment guidelines

All of the following requirements must be met in order for a hospital to receive an APC payment for the extended assessment and management composite APCs:

1. Observation Time

a. Observation time must be documented in the medical record.

b. A beneficiary’s time in observation (and hospital billing) begins with the beneficiary’s admission to an observation bed.

c. A beneficiary’s time in observation (and hospital billing) ends when all clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be released or admitted as an inpatient.

d. The number of units reported with HCPCS code G0378 must equal or exceed 8 hours.

2. Additional Hospital Services

a. The claim for observation services must include one of the following services in addition to the reported observation services. The additional services listed below must have a line item date of service on the same day or the day before the date reported for observation:

• An emergency department visit (CPT code 99284 or 99285) or

• A clinic visit (CPT code 99205 or 99215); or

• Critical care (CPT code 99291); or

• Direct admission to observation reported with HCPCS code G0379, must be reported on the same date of service as the date reported for observation services.

b. No procedure with a “T” status indicator can be reported on the same day or day before observation care is provided.

3. Physician Evaluation

a. The beneficiary must be in the care of a physician during the period of observation, as documented in the medical record by admission, discharge, and other appropriate progress notes that are timed, written, and signed by the physician. b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.

4. Payment for Direct Admission to Observation

For CY 2008, direct admission to observation care continues to be reported using HCPCS code G0379 (Direct admission of patient for hospital observation care). Hospitals should report G0379 when observation services are the result of a direct admission to observation care without an associated emergency room visit, hospital outpatient clinic visit, critical care service, or surgical procedure (T status procedure) on the day of initiation of observation services. Hospitals should only report HCPCS code G0379 when a patient is admitted directly to observation care after being seen by a physician in the community.

Payment for direct admission to observation will be made either separately as a low level hospital clinic visit under APC 604, packaged into payment for composite APC 8002 (Level I Prolonged Assessment and Management Composite), or packaged into payment for other separately payable services provided in the same encounter.

The criteria for payment of HCPCS code G0379 under either APC 8002 or APC 0604 include:

1. Both HCPCS codes G0378 (Hospital observation services, per hr) and G0379 (Direct admission of patient for hospital observation care) are reported with the same date of service.

2. No service with a status indicator of T or V or Critical Care (APC 0617) is provided on the same date of service as HCPCS code G0379.

If either of the above criteria is not met, HCPCS code G0379 will be assigned status indicator N and will be packaged into payment for other separately payable services provided in the same encounter.

Composite APCs and Criteria for Composite Payment Composite APC

Composite APC Title Criteria for Composite Payment 8000 Cardiac Electrophysiologic

Evaluation and Ablation Composite

At least one unit of CPT code 93619 or 93620 and at least one unit of CPT code 93650, 93651 or 93652 on the same date of service 8001 Low Dose Rate Prostate

Brachytherapy Composite One or more units of CPT codes 55875 and 77778 on the same date of service 8002 Level I Extended Assessment and Management Composite

1) 8 or more units of HCPCS code G0378 are billed–

* On the same day as HCPCS code G0379; or

* On the same day or the day after CPT codes 99205 or 99215 and

2) There is no service with SI=T on the claim on the same date of service or 1 day earlier than G0378

8003 Level II Extended Assessment and Management Composite

1) 8 or more units of HCPCS code G0378 are billed on the same date of service or the date of service after 99284, 99285 or 99291 and

2) There is no service with SI=T on the claim Composite APC Composite APC Title Criteria for Composite Payment on the same date of service or 1 day earlier than G0378.

0034 Mental Health Services Composite

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Medical Billing Modifier Guide

CPT modifiers update

(2023) CPT Code 99285 | Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code 99285 is an Emergency Department (ED) code typically reported daily and does not differentiate between new or established patients. This article will help you with proper coding, billing guidelines, modifiers , and reimbursement for CPT 99285.

Description Of CPT Code 99285

There are five levels under the emergency department services category represented by 99281-99285. All decks require documenting the three key components (history, exam, and medical decision-making [MDM]).

CPT code 99285 is the uppermost level of this series.

99285 CPT code – ED visit for the Evaluation and management of a patient, which requires these three components within the limitation imposed by the urgency of the patient’s clinical condition and mental status:

A comprehensive history
A comprehensive examination
Medical decision-making of high level.

All three components mentioned above must be met or exceeded for the level of service selected. Time is not a factor when selecting this E/M Service. An ED is typically an organized facility available 24 hours a day, providing unscheduled services to patients needing urgent medical attention.

Counseling & conciliation of care with other physicians, other health professionals, or agencies are provided consistent with the nature of the problem. The patient’s or family’s needs are also included. Usually, the reporting problems are highly severe and pose an immediate significant threat to life or physiologic function.

CPT code 99285 reports emergency department services for new or established patients.

Coding Tips

Report place of service (POS) code 23 for services provided in the hospital emergency room.

Medicare has provisionally identified these codes as telehealth/telemedicine services.

Current Medicare coverage guidelines, including place of service, should be checked.

For coverage guidelines, commercial payers should be contacted.

Only the medically necessary portion of the Emergency Department visit is allowed by Medicare.

Though if a complete note is generated at the time of the visit, only the necessary services for the patient’s condition can be considered in determining the level of an E/M code. Medical necessity must be clearly stated and support the level of service reported.

Medical necessity is the Diagnosis code reported to tell the payer why service is performed. For a service to be considered medically necessary, diagnosing or treating a patient’s medical condition must be reasonable and necessary.

When selecting the E/M code 99281 – CPT code 99285 , comorbidities and other underlying health conditions in and of themselves are not considered Until unless their presence significantly increases the complexity of the medical decision-making.

The time spent only face to face with the Physician is considered in selecting an E&M level performed in the emergency department. The time spent by other staff, including nurses, practitioners, etc., is NOT considered when choosing the appropriate service level.

Billing Guidelines

The level of E&M service billed must be based on the treatments performed concerning the medical care required by the reported symptoms and resulting in the patient’s diagnosis. Professional codes are based on complexity and accomplished work, including the “cognitive” effort.

Only one unit of CPT code 99285 is allowed to bill on the same day.

E&M CPT code 99285 is not reimbursable to the same provider more than once.

The Cost and total RVUs of 99285 CPT code are $178.91 and 5.17000 respectively for both National and Global Facility and Non-Facility Services.

Facility codes reflect the volume and ferocity of resources used by the facility to provide care.

While billing, Claims should be submitted with supportive Documents when requested by the provider to support the level of care rendered. The documentation must identify and support ED E/M codes billed. The documents that support it must be included in the appeal request if a denial is appealed.

CPT Code 99285

Three critical components within the limitations imposed by the necessity and urgency of the patient’s clinical condition and mental status are given below for the Evaluation and management of a patient in the Emergency department:

Detailed history
Detailed exam
MDI (Medical decision making) of severe complexity
Reason for encounter
Problem relevant ROS (Review of systems)
Extended HPI – An extended HPI consists of four or more elements of the HPI . The medical records should include all aspects.

Review of Systems

ROS directly related to the identified condition.

Medically necessarily review of all body systems history.

Complete past, social, and family history.

History of Present Illness

A Sequential description of the development of the patient’s present illness from the first sign or the initial encounter to the present. Descriptions of current condition may include:

Location, Quality, Severity of illness,

Timing: which time does it worsen/alleviate,

Context and Modifying factors,

Relative signs or symptoms to the presenting problem.

Chief Complaint

The Chief Complaint is a brief statement from the patient describing specific symptoms, condition, problem, diagnosis, and Physician recommended return or other factors that are the primary purpose of the patient’s admission.

A review of systems is usually done by asking a series of questions from the patient and identifying physical signs and symptoms to rule out the illness.

ROS, the Following systems are reviewed:

Constitutional ( fever , weight loss , etc.), Eyes, Ears, Nose, Mouth, Throat, Cardiovascular, Allergic/Immunologic Respiratory, Musculoskeletal, Integumentary (skin and breast), Gastrointestinal, Neurologic, Psychiatric, Endocrine, Genitourinary, and Hematologic/Lymphatic.

Past, Family, and Social History (PFSH)

It consists of a review of the following:

Patient’s past illnesses, surgeries, injuries, and treatments.

Family History: medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk.

Social History: an age-appropriate present and past ADLs (Activities of Daily living).

Practitioner/Clinician choosing to use time as the determining factor:

Document time in the patient’s medical record.
The documentation should have to support sufficient detail about the nature of the counseling.
Code selection should be based on the total time of the encounter. The medical record should be documented sufficiently to justify the code selection.

Reimbursement

Reimbursement and payment determination are subject to, but not limited to:

Group or Individual benefit,
Provider Participation Agreement,
Mutually exclusive logic and medical necessity,
Mandated or legislatively required criteria will always be supplanted.

Medicare Providers are responsible for confirming and ensuring that visits are coded accurately. A Distinct provider number is used when a service is billed to ensure that the provider has reviewed and verified the accuracy of everything on the submitted claim.

The patient’s condition to ensure claims submitted with the correct level of service should be documented clearly

In some cases where the provider participates, co -payment, coinsurance, and deductible should be applied based on member benefits.

Modifiers With Examples

Modifiers provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Modifiers that are applicable with CPT code 99285 are given below

Modifiers often used in medical coding for CPT code 99285 are 24, 25, and 57.

Below are the descriptions and usage of these modifiers.

Modifier 24

Unrelated E&M service given by the Same Physician or Other Qualified Health Care Professional During a global period (postoperative) of an effective procedure.

Modifier 24 is appended with the E&M code when a patient is in the global fee period of a major or minor procedure performed within the global fee period. Still, They returned for a different condition or procedure with another Diagnosis code.

If a patient had total hip arthroplasty one month ago, he comes again for Evaluation and management of abdominal pain. So modifier 24 should be appended to 99285 CPT code to distinguish it as an unrelated E&M service. A patient would not be counted as a part of the global fee period.

Modifier 25

Separate identifiable E&M service performed by the Same Physician or Other Qualified Health Care Professional on the Same Day when another minor or major procedure is performed.

Use modifier 25 always when the Evaluation and management service is Distinct, significantly identifiable, and separately documented as another service different from the E&M service.

Use modifier 25 on an E/M service performed during the same session as a preventive care visit when significant, separately identifiable E/M service is rendered in addition to the preventive care. ICD 10 (Diagnosis) Code should identify the service as non-preventive.

A patient comes to the ED for severe knee pain, and the doctor performs arthrocentesis of the knee joint. In this case, modifier 25 would be appended to the CPT code 99285, describing the arthrocentesis as a different procedure.

Modifier 57

57- “ Decision for surgery.” An E&M service resulted in the decision to perform the significant/major surgery identified by using a 57-modifier to the appropriate level of E/M service.

Use Modifier 57 to indicate an Evaluation and Management (E/M) service when the initial decision to perform surgery is the day before major surgery (90 days global) or the day of major surgery.

A patient came to the ED after having a Road traffic accident. He fractured his lower leg. The doctor decides to do significant surgery ORIF (Open reduction Internal fixation). So, in this case, modifier 57 would be appended to CPT code 99285.

Billing Examples

The following list examples of when the 99285 CPT code may be billed.

Emergency department visit for a patient with complicated overdoes requiring aggressive management to prevent side effects from the ingested materials.

Emergency department visit for a patient with a new onset of rapid heart rate requiring IV drugs.

Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.

Emergency department visit for a previously healthy young adult patient who is injured in an automobile accident and is brought to the emergency department immobilized and has symptom compatible with intra-abdominal injuries or multiple extremity injuries.

Emergency department visit for a patient with an acute onset of chest pain compatible with cardiac ischemia and/or pulmonary embolus symptoms.

Emergency department visit for a patient who presents with a sudden onset of ‘’the worst headache or her life,” and complains of a stiff neck, nausea, and inability to concentrate.

Emergency department visit for a patient with a new onset of a cerebral vascular accident.

Emergency department visit for acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness.

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2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

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Explore This Issue

The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

99281: ED visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
99282: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
99283: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
99284: ED visit for the evaluation and management of a patient which requires a medically appropriate history and/or examination and moderate medical decision making.
99285: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

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Emergency Department Visits

Emergency department (ED) services are E/M services provided to patients in the Emergency Department.

Explanation

These services may be billed by any specialty physician, not just Emergency Department physicians. The physician does not need to be assigned to the ED. However, these codes may only be used in a hospital-based facility that is available 24 hours/day for unscheduled care to patients who present for immediate medical attention.

99282, 99283, 99284, 99285 – Emergency Department Visits, and in some cases, the office (99202-99215) and outpatient/consult codes (99242-99245.)

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Last revised December 12, 2023 - Betsy Nicoletti Tags: emergency department

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Selecting the appropriate level of service.

Emergency Department Visits Based on 1995 and 1997 Guidelines*

Can Critical Care Be Reported When Performed in the ED?

Reporting procedures, can the special services codes be reported with the ed codes, coding for emergency department visits.

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American Academy of Pediatrics; Coding for Emergency Department Visits. AAP Pediatric Coding Newsletter February 2007; 2 (5): No Pagination Specified. 10.1542/pcco_book034_document002

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Reference Manager

Current Procedural Terminology (CPT ® ) codes 99281–99285 are used to report evaluation and management (E/M) services provided in the emergency department (ED). CPT defines an ED as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

This definition clearly precludes the use of codes 99281–99285 when E/M services are performed in an urgent care center or any freestanding facility that is not hospital-based or open for 24 hours a day. Services performed in those settings must be reported with CPT codes 99201–99205 (office/outpatient E/M services) because they do not meet the CPT definition of an ED.

The use of the ED E/M codes is not exclusive to ED physicians (ie, primary ED staff physician). However, there are caveats in that only one physician can report the ED codes for any single ED patient visit. The following examples demonstrate how the services should be reported when 2 physicians provide services for a single ED patient visit.

An office-based physician asks a patient to meet him or her at the ED for care. The ED physician does not treat the patient. The attending office-based physician would report the ED E/M codes based on the level of service provided and documented.

A patient is seen by the ED physician, who decides to transfer the care of the patient to another physician. The ED physician (Physician A) will report the ED E/M code and the physician assuming the care of the patient (Physician B) will report an office or outpatient E/M code (99201–99215). If the patient is admitted by Physician B during the course of the visit, the initial observation (99218–99220) or initial hospital care (99221–99222) codes will be alternatively reported. (If the patient is admitted and discharged on the sameday of service, codes 99234–99236 would be alternatively reported). The level of service reported for the admissionis based on all of the E/M services provided by the admitting physician during the course of the day. Remember that CPT guidelines specify that when a patient is admitted to the hospital (either inpatient or observation status) in the course of an encounter in another site of service (eg, hospital ED), all E/M services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date of service.

The ED physician (Physician A) requests a consultation from another physician (Physician B). The ED physician (Physician A) will report the appropriate-level ED code and the consulting physician (Physician B) will report the consultation using the office or other outpatient consultation codes (99241–99245). If Physician B admits the patient from the ED, only the initial hospital care code (99221–99223) will be reported. If Physician B makes the decision to perform surgery, modifier 57 should be appended to the reported E/M code.

A patient meets his physician (Physician A) at the ED. A second physician (Physician B) treats the patient at the request of Physician A. Physician B will report his services as a consultation (if the requirements for reporting a consultation are met) or as an office or outpatient E/M service. Physician A will report the appropriate ED service.

A patient is seen in the ED by Physician A. Physician A admits the patient to observation. Only the initial observation (99218–99220) service will be reported based on the level of care provided by Physician A in the ED and as part of the initial observation care. Or, the ED physician writes “holding” admission orders for a patient being admitted under another physician's service. The admitting physician will then report only the initial observation care (99218–99220).

Tip: All services provided in the ED should be reported with place of service code 23.

The performance and documentation of all 3 key components (history, physical examination, and medical decision-making) are used to select the level of an ED E/M code. Three additional components (counseling, coordination of care, and the nature of the presenting problem) are contributory factors and are not required for the selection of a code. CPT has not assigned any average or typical time to this family of codes because of the unpredictability and inconsistency in the intensity of the service. Therefore, time cannot be used as a key or controlling factor in the selection of the code.

Note that the description of service for CPT code 99285 states that use of this code requires the performance of the “three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status.” This means that code 99285 may be reported if the patient's condition requires a comprehensive history and physical examination but circumstances prevent the physician from obtaining a comprehensive history and/or completing a comprehensive physical examination. (In addition, the patient's condition would require a high level of medical decision-making.)

Tip: The medical record documentation must state the reason that a comprehensive history and/or physical examination were unable to be performed.

The Table on page 7 summarizes the key components required for each ED E/M code based on the 1995 and 1997 Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines for E/M Services. Note that there is no distinction between new or established patients.

*Three of 3 key components must be met.

† HPI, history of present illness; ROS, review of systems; PFSH, past family and social history.

Tip: Physicians may use either the 1995 or 1997 CMS Documentation Guidelines. Most physicians find the 1995 guidelines easier to follow, while some specialists may find the 1997 guidelines to be more applicable. Note that CPT guidelines for a comprehensive examination differ from the 1995 CMS Documentation Guidelines in that there is no limit to the number of systems required for a multisystem examination. Most payers, including state Medicaid programs, rely on the 1995 or 1997 CMS Documentation Guidelines. You can access both sets of guidelines at www.cms.hhs.gov/MedlearnProducts/20_DocGuide.asp .

Critical care services (99291–99292) can be reported when performed in the ED if the care of the critically ill or injured patient is based on the CPT definition of critical care. Critical care and an ED visit may be reported by the same physician when performed on the same day of service. However, there must be 2 distinct services provided. If only critical care services are provided, codes 99291 (critical care, first 30–74 minutes) and 99292 (each additional 30 minutes) are reported based on the total time the physician spends in the provision of the critical care services. The neonatal and pediatric critical care services (99293–99296) cannot be reported because they are restricted to inpatients only. The critical care services are reported based on the total time spent face to face with the patient or time spent performing work directly related to the patient's care. Remember that critical care codes are bundled services and include many procedures. The time spent performing any procedures that are not bundled (and therefore are billable) with the critical care service codes must be excluded from the time spent providing critical care.

For example, an infant presents to the ED after being found in the family's pool. The infant is not breathing and is intubated and resuscitated for 35 minutes. In this example, only codes 31500 (endotracheal intubation) and 92950 (cardiopulmonary resuscitation [CPR]) would be reported because both procedures are not bundled and cannot be counted as critical care time. However, if critical care services are provided for 30 minutes before the infant requires resuscitation, the procedures may be reported in addition to the critical care (99291). What if CPR was performed for 10 minutes and the infant was stabilized and sent to the intensive care unit (ICU) 25 minutes later? In this situation an ED visit (99285) , intubation (31500) , and CPR (92950) would be reported. Critical care services would not be reported in this case because less than 30 minutes was spent providing critical care.

Consider this example of when both an ED visit and critical care might be reported. A child is seen for injuries following an automobile accident. A comprehensive history and physical examination are performed. While under observation and waiting for radiology, the child goes into respiratory arrest. Critical care is then initiated and continues for 45 minutes. In this example, both an E/M service (99285) and critical care (99291) were provided. Any procedures that are not bundled with critical care would also be reported and the time spent in performing them would be deducted from the total critical care time. Conversely, if critical care is provided for 30 or more minutes and the patient then stabilizes and does not require critical care, an ED E/M service may be reported if a significant, separately identifiable service is performed and documented.

Tip: Critical care is considered to be an E/M service. Therefore, when a procedure or service is performed on the same day, modifier 25 should be appended to the critical care codes.

Procedures performed by the physician can be reported in addition to the ED E/M service. Because ED services are provided in a hospital facility, services performed by hospital staff are reported by the facility and not by the ED physician. (They are not considered incident-to services.) For example, the ED physician would not report a routine venipuncture (36415). However, if the venipuncture required the physician's skill, codes 36400–36410 would be reported by the physician.

Examples of some of the procedures that are routinely performed in the ED include burn care, intubation, incision and drainage of abscesses, insertion of chest tubes, and resuscitation.

Third-party payer policies may guide billing for certain procedures. It is common for the ED physician to repair lacerations and refer the patient to his or her primary care physician for removal of the sutures. Although laceration repair is considered part of the CPT surgical package or Medicare global period, payers have recognized this practice and will typically reimburse the ED physician for the repair and another physician for the E/M visit required to remove the sutures. However, payment for more complex procedures is considered to be a bundled service inclusive of the preoperative care, surgical procedure, and associated postoperative care. For example, if the ED physician reports a fracture care code and sends the patient to an orthopaedic physician for all follow-up care, the payer may not make separate payment for the follow-up care because payment for the global service was made to the ED physician. There are several options for billing global surgery procedures performed in the ED. Using fracture care as an example, the following options can be used to bill global surgery services performed in the ED: (1) If the ED physician performs the fracture care and follow-up management, the fracture care code can be reported; (2) the ED physician can report the fracture care with modifier 54 (surgical care only) if he or she performs a significant portion of the global fracture care; or (3) the ED physician can report an ED E/M service and splinting (if performed personally by the physician), allowing the orthopaedic surgeon to report the fracture care.

Tip: If billing the fracture care with modifier 54, the ED physician should coordinate billing with the orthopaedic physician. The orthopaedic physician then knows to report his or her services using modifier 55 (postoperative care only).

The special services code that may be used by an ED physician (staff physician) in addition to the basic service(s) provided is CPT code 99053 (service[s] provided between 10:00 pm and 8:00 am at 24-hour facility, in addition to basic service). If appropriate, a non-ED physician could report CPT code 99056 (services[s] typically provided in office, provided out of office at request of patient, in addition to basic service) or 99060 (service[s] provided on an emergency basis, out of office, which disrupts other scheduled office services, in addition to basic service).

According to CPT , any physician of any specialty may report any procedure or service; however, payers will follow their individual policies for coverage and/or payment of these adjunct service codes.

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Welcome to our informative guide on the 99283 CPT code for emergency department visits. In this article, we will provide you with a detailed understanding of this code and its significance in healthcare billing and reimbursement. Whether you are a healthcare professional or simply seeking information about ER coding, we’ve got you covered.

When patients visit the emergency department, their medical services are categorized and reported using specific codes. One such code, the 99283 CPT code, is assigned to ER visits that require an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity. This code is commonly associated with level 3 ER visits, which involve patients with moderate severity presenting problems.

Key Takeaways:

The 99283 CPT code is used for reporting emergency department visits.
This code corresponds to level 3 visits, which involve moderate severity presenting problems.
The code requires an expanded problem focused history, examination, and moderate complexity in medical decision making.
Accurate coding and documentation are crucial for proper reimbursement.
Medical Bill Gurus can assist healthcare providers with medical billing services and navigating the reimbursement process for the 99283 code.

Now that we’ve provided you with an overview, let’s dive deeper into the components of the 99283 CPT code and understand its relevance in emergency department visits.

What is a CPT Code?

CPT codes, or Current Procedural Terminology codes, are a set of medical codes used to describe medical procedures and services provided by healthcare professionals. These codes play a crucial role in healthcare billing and reimbursement. They provide a standardized way to communicate the specific procedures and services rendered, allowing for accurate documentation and proper categorization for billing purposes.

One commonly used CPT code in the field of evaluation and management is the 99283 code. This code is specifically assigned to emergency department visits and falls under the category of evaluation and management codes. It is used to report emergency visits that require an expanded problem-focused history, an expanded problem-focused examination, and medical decision making of moderate complexity.

Healthcare providers rely on CPT codes to accurately bill for their services and receive appropriate reimbursement from insurance companies or government programs such as Medicare. These codes serve as a universal language in the healthcare industry, bridging the gap between healthcare providers and payers.

Benefits and Importance of CPT Codes

The utilization of CPT codes offers several benefits:

Standardization: CPT codes provide a standardized method for documenting and reporting medical procedures and services across various healthcare settings. This uniformity enhances communication and reduces ambiguity.
Precision in Billing: CPT codes ensure precise billing by accurately representing the complexity and nature of the medical services provided. This helps healthcare providers receive fair and appropriate reimbursement.
Comparative Analysis: CPT codes allow for comparisons between different procedures and services. These comparisons assist in analyzing healthcare trends, assessing outcomes, and determining the cost-effectiveness of certain treatments.
Reimbursement: Accurate coding using CPT codes is essential for healthcare providers to receive timely reimbursement for the services they render. Proper documentation and assignment of CPT codes significantly reduce the risk of claim denials.

In summary, CPT codes are a critical component of healthcare billing and reimbursement. They enable accurate representation and communication of medical services, ensure fair reimbursement for healthcare providers, and facilitate efficient analysis of healthcare data. The 99283 code specifically captures the evaluation and management aspects of emergency department visits, providing a well-defined categorization for billing purposes.

Components of the 99283 CPT Code

The 99283 CPT code encompasses three essential components that must be fulfilled for accurate reporting. These components consist of an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity. Proper documentation should highlight the presence of these components to ensure precise coding and billing.

New Patient Visit – Level 3

When using the 99283 CPT code, the expanded problem focused history involves obtaining a detailed account of the patient’s current condition, symptoms, and medical history. This includes relevant information about the presenting problem, any known allergies or medications, and the patient’s past medical, surgical, and family history.

The expanded problem focused examination requires a systematic assessment of the patient’s affected body areas and organ systems related to the presenting problem. Medical practitioners evaluate the patient’s vital signs, perform targeted physical examinations, and document any observed abnormalities or findings related to the chief complaint.

Medical decision making of moderate complexity involves the evaluation and analysis of the patient’s medical condition, diagnostic test results, and treatment options. The practitioner assesses the information collected during the history and examination to derive a diagnosis, determine the appropriate management plan, and ensure patient safety.

By accurately documenting and fulfilling these three components, healthcare providers can ensure proper coding and billing for emergency department visits that meet the criteria for the 99283 CPT code.

Emergency Department Visits and Coding Guidelines

When it comes to coding emergency department visits, following specific coding guidelines is crucial. According to the Current Procedural Terminology (CPT) definition, an emergency department is a hospital-based facility that provides unscheduled episodic services to patients who require immediate medical attention.

To accurately code an ER visit, it is essential to document the level of history, examination, and medical decision making. This documentation ensures the assignment of the appropriate CPT code, reflecting the complexity of the visit. Proper documentation is essential for accurate coding and compliant billing.

Let’s take a closer look at the key aspects of coding guidelines for emergency department visits.

Documentation Requirements

When coding an emergency department visit, thorough documentation is essential to accurately reflect the level of service provided. The documentation should include:

A detailed history of the patient’s chief complaint and presenting problems
A comprehensive examination, including vital signs, physical findings, and any diagnostic tests performed
Medical decision making that demonstrates the complexity of the patient’s condition and the management involved

By documenting these elements, healthcare providers ensure compliance with coding guidelines and enable accurate coding and billing of emergency department visits.

Coding Guidelines for Emergency Department Visits

When coding an emergency department visit, the key considerations include:

Selecting the appropriate CPT code based on the complexity of the visit
Following the CPT guidelines to ensure accurate code assignment
Adhering to any specific payer requirements or modifiers, if applicable

It is important to note that CPT codes for emergency department visits are categorized based on the level of complexity, such as problem-focused, expanded problem-focused, or detailed examination. Choosing the correct code is crucial for proper reimbursement and compliance with coding guidelines.

Understanding the coding guidelines for emergency department visits is paramount to ensure accurate coding and compliant billing. By carefully documenting the necessary information and selecting the appropriate CPT code, healthcare providers can submit claims that reflect the complexity of the services provided during an emergency department visit.

Reimbursement Process for 99283 CPT Code

Reimbursement for the 99283 CPT code is a critical aspect of the healthcare billing process. The amount of reimbursement received for an emergency department visit depends on various factors, including the payer’s policies and the documentation supporting the level of service provided. Accurate coding and thorough documentation are essential to ensure proper reimbursement for healthcare providers.

At Medical Bill Gurus, we understand the complexities of the reimbursement process and can assist healthcare providers in navigating through the intricacies. Our team of experienced professionals is well-versed in the coding guidelines and documentation requirements for the 99283 CPT code. We can help providers optimize their revenue by ensuring accurate coding and comprehensive documentation.

When it comes to reimbursement, every detail matters. The documentation supporting the level of service provided must align with the assigned CPT code, specifically the expanded problem focused history, expanded problem focused examination, and medical decision making of moderate complexity. By accurately coding and documenting the visit, healthcare providers can maximize their reimbursement and avoid potential claim denials.

Medical Bill Gurus works closely with healthcare providers, offering comprehensive medical billing services tailored to their specific needs. We have extensive experience in navigating the reimbursement process, ensuring that our clients receive the appropriate reimbursement for the services they provide. With our expertise, you can focus on delivering quality patient care while we handle the complex billing and reimbursement processes.

Trust Medical Bill Gurus to be your partner in optimizing revenue and streamlining the reimbursement process. Contact us today to learn more about our medical billing services and how we can assist you in navigating the reimbursement process for the 99283 CPT code.

Medical Bill Gurus – Your Medical Billing Company

At Medical Bill Gurus, we understand the complexities of medical billing and the importance of accurate coding for healthcare providers. Led by President Daniel Lynch, our team specializes in providing comprehensive medical billing services tailored to the unique needs of each provider.

With our expertise in working with all insurance payers, including Medicare, we can help you optimize your revenue through accurate coding and billing practices. Our dedicated team is committed to ensuring your financial success by staying up-to-date with the latest coding guidelines and reimbursement processes.

When you partner with Medical Bill Gurus, you can expect:

Accurate and timely submission of claims
Thorough documentation and coding reviews to maximize reimbursement
Personalized support and guidance throughout the billing process
Transparent reporting to track your revenue and identify areas for improvement
Compliance with HIPAA rules and regulations to protect patient confidentiality

Our goal is to streamline your billing operations, reduce administrative burden, and help you focus on providing quality patient care. Trust Medical Bill Gurus to be your dedicated partner in medical billing.

The Importance of Accurate Coding

Accurate coding is crucial for healthcare providers as it directly impacts the reimbursement they receive for their services. Proper coding ensures that the services provided are reflected accurately in billing claims, which in turn affects reimbursement rates. Accurate documentation is essential to support the assigned codes and prevent denial of claims.

Why Accurate Coding Matters

Accurate coding plays a significant role in healthcare billing and reimbursement. When the wrong code is assigned or documented inaccurately, it can result in payment delays, denials, or even potential legal issues. Healthcare providers rely on accurate coding to receive fair compensation for their services and maintain financial stability.

Accurate coding also helps healthcare providers in the following ways:

Transparent and Consistent Billing: Accurate coding ensures that the services provided are transparently communicated through billing claims. It allows payers, such as insurance companies, to understand the nature and complexity of the services rendered.
Avoidance of Overbilling or Underbilling: Accurate coding prevents overbilling, which can result in audits, financial penalties, and damaged professional reputation. Conversely, underbilling can lead to revenue loss and unsustainable financial practices.
Compliance with Regulatory Standards: Proper coding ensures compliance with regulatory standards, such as the Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases (ICD). Adhering to these standards helps healthcare providers avoid legal and compliance issues.

The Role of Documentation

Accurate documentation is a crucial component of accurate coding. It provides evidence to support the assigned codes and justifies the level of service provided. Comprehensive and detailed documentation helps healthcare providers avoid claim denials and provides a clear record of the patient’s condition and treatment.

Documentation should:

Include relevant patient information, such as medical history, chief complaint, and relevant clinical findings.
Specify the complexity of the medical decision making involved.
Outline the extent of the problem-focused history and examination conducted.

Proper documentation should align with the coding guidelines and accurately reflect the services rendered. It is essential to maintain clear and consistent records that can withstand audits or reviews.

Accurate coding and documentation are essential components of efficient healthcare billing and reimbursement. By ensuring the right codes are assigned and supported by comprehensive documentation, healthcare providers can maximize their revenue, maintain compliance, and provide quality care to their patients.

Understanding the Level 3 ER Visit

When a patient presents with moderate severity problems in the emergency department, it is typically categorized as a level 3 ER visit. The 99283 CPT code is commonly assigned to these visits, as it reflects the expanded problem focused history, expanded problem focused examination, and medical decision making of moderate complexity involved in the evaluation and management of the patient.

Coding Reminder and HIPAA Rules

When it comes to coding and reimbursement processes, it is crucial to stay updated with the ever-evolving coding rules and guidelines. At our company, we prioritize compliance with the Health Insurance Portability and Accountability Act (HIPAA) rules, which govern medical code sets such as CPT, HCPCS, and ICD-9-CM. By adhering to these regulations, we ensure the privacy and security of patient health information while accurately documenting and coding medical services.

It is essential to use valid codes that are relevant to the date of service. Submitting or accepting only valid codes prevents coding errors and promotes accurate billing and reimbursement. We are continuously monitoring coding changes and updates to provide our clients with the most up-to-date coding practices and ensure compliance with HIPAA guidelines.

As coding guidelines continue to evolve, it is crucial for healthcare providers to partner with a trusted medical billing company that has a deep understanding of these changes and can navigate through the coding process effectively. At Medical Bill Gurus, we are committed to providing reliable and accurate medical billing services while adhering to the latest coding guidelines and HIPAA rules.

Stay informed and compliant with our expert team of medical billers who are well-versed in coding practices and HIPAA regulations. Let us handle your medical coding and billing needs, allowing you to focus on delivering exceptional patient care. Trust our expertise and experience in maximizing your revenue while ensuring compliance with coding rules and HIPAA guidelines.

Key Features of Our Coding Reminder and HIPAA Compliance:

Regular updates on coding changes and guidelines
Awareness of HIPAA rules and regulations
Adherence to coding standards and best practices
Accurate documentation and coding of medical services
Secure handling of patient health information

Let us help you navigate the complex world of medical coding and reimbursement, ensuring compliance with HIPAA rules and optimizing your revenue. Contact us today to learn more about our comprehensive medical billing services.

Contact Medical Bill Gurus

If you have any questions or need assistance with medical billing services, you can contact our provider services at the following phone numbers:

(651) 662-5200
Toll-free: 1-800-262-0820

Our dedicated team at Medical Bill Gurus is ready to address any inquiries you may have. Whether you need help with coding, billing, or navigating the reimbursement process, we are here to assist you. Contact us today to learn more about our comprehensive medical billing services.

Medicare Guidelines for the 99283 CPT Code

When it comes to the 99283 CPT code, Medicare follows specific guidelines for reimbursement and documentation. It’s important to understand these guidelines in order to ensure proper reimbursement for Medicare patients. Here are some key points to keep in mind:

Reimbursement Rates

The reimbursement rates for the 99283 code may vary for Medicare patients. Medicare sets national facility and non-facility total payment rates for this code. It’s essential to check the specific reimbursement rates applicable to your region to ensure accurate billing. The table below provides an overview of the Medicare reimbursement rates for the 99283 code:

Note: The reimbursement rates provided in the table are for illustrative purposes only and may not reflect current rates. Please refer to the official Medicare documentation for the most up-to-date reimbursement rates.

Proper documentation is crucial when coding and billing for Medicare patients. Medicare has specific documentation requirements that must be met to support the level of service provided. It’s essential to accurately document the expanded problem focused history, expanded problem focused examination, and medical decision making of moderate complexity. Failure to meet these documentation requirements may result in claim denials or audits.

We understand the importance of adhering to Medicare guidelines, which is why at Medical Bill Gurus, we stay up-to-date with the latest coding and billing regulations. Our team of experts can assist you in navigating the Medicare reimbursement process, ensuring accurate coding and maximizing your revenue. Contact us today to learn more about our medical billing services.

Reimbursement Rates for 99283 CPT Code

The reimbursement rates for the 99283 CPT code can vary depending on the payer and geographic location. It is crucial to understand these rates to ensure accurate billing and reimbursement. Medicare, for example, sets national facility and non-facility payment rates for the 99283 code.

Here is an overview of the reimbursement rates for the 99283 CPT code:

Please note that these rates are for illustrative purposes only and may not represent the current reimbursement rates. It is essential to check with each specific payer to determine the accurate rates for the 99283 CPT code.

Global Days and CPT Coding

The concept of global days does not apply to the 99283 CPT code. Global periods are timeframes during which all related services for a procedure or surgery are considered part of the initial service and are not billed separately. However, this concept does not apply to the 99283 code since ER visits are typically standalone services.

When it comes to the 99283 CPT code, there is no need to worry about global periods or bundled services. This code specifically captures the evaluation and management of patients in the emergency department, and each visit is treated as a separate entity. It means that all the services provided during an ER visit, from the history and examination to the medical decision-making, can be coded and billed independently.

Unlike surgical procedures that have healing periods and post-operative care included in global periods, ER visits are not subject to the same rules. Therefore, you can confidently report and code the 99283 CPT code without considering any global days or bundled services.

Next, we’ll dive into more details about the bundled services and related CPT codes for emergency department visits. Stay tuned!

Bundling Information for 99283 CPT Code

The 99283 CPT code encompasses bundled services that are included in the reporting of this code. These bundled services should not be reported separately when the main code, 99283, is used. Included services range from laboratory tests and procedures to counseling and coordination of care with other healthcare professionals.

When using the 99283 CPT code, it’s important to understand which services are bundled and should not be reported separately. This helps ensure accurate coding and billing, preventing potential claim denials and ensuring proper reimbursement. The bundled services for the 99283 code vary depending on the specific circumstances and the medical necessity of the services provided.

To illustrate the bundled services within the 99283 CPT code, the following table provides an overview:

It’s crucial to understand that these bundled services are not reported separately when the 99283 CPT code is used. Proper documentation of the bundled services provided during the ER visit is essential for accurate coding and billing.

Related CPT Codes

When coding for emergency department visits, healthcare providers should be familiar with several related CPT codes. These codes encompass various levels of visits, procedures, and counseling services. It is crucial to carefully review the documentation and select the most appropriate code based on the level of service provided. By accurately coding the services, healthcare providers can ensure proper reimbursement and compliance with billing guidelines.

Commonly Used Related CPT Codes

Below are some commonly used related CPT codes for emergency department visits:

These are just a few examples of the related CPT codes used for emergency department visits. It is essential to consult the complete CPT code set and any applicable coding guidelines to ensure accurate coding and billing.

In conclusion, understanding the 99283 CPT code is crucial for accurate coding and billing of emergency department visits. This code, commonly assigned to level 3 ER visits, reflects the expanded problem focused history, examination, and medical decision making of moderate complexity involved in evaluating and managing patients. By following coding guidelines and accurately documenting the services provided, healthcare providers can ensure proper reimbursement for their efforts.

At Medical Bill Gurus, we offer comprehensive medical billing services to assist healthcare providers in optimizing their revenue and navigating the complex coding and reimbursement process. Our team, led by President Daniel Lynch, specializes in working with all insurance payers, including Medicare. We can help healthcare providers streamline their billing practices and maximize their reimbursement rates.

If you need assistance with your medical billing needs, whether it’s understanding the 99283 CPT code or navigating the reimbursement process, contact Medical Bill Gurus. Our provider services team is available at (651) 662-5200 or toll-free at 1-800-262-0820 to address your inquiries and provide further information about our services. Let us help you optimize your revenue and ensure accurate coding and billing practices.

What is the 99283 CPT code?

The 99283 CPT code is used for reporting emergency department visits that require an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity. It is often assigned to level 3 ER visits.

What is a CPT code?

CPT codes, or Current Procedural Terminology codes, are a set of medical codes used to describe medical procedures and services provided by healthcare professionals. The 99283 code falls under the category of evaluation and management codes, specifically for emergency department visits.

What are the components of the 99283 CPT code?

The 99283 CPT code requires an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity.

What are the coding guidelines for emergency department visits?

Emergency department visits have specific coding guidelines that must be followed. It is important to document the level of history, examination, and medical decision making in order to assign the appropriate CPT code.

How does the reimbursement process work for the 99283 CPT code?

Reimbursement for the 99283 CPT code is dependent on various factors, including the payer’s policies and the documentation supporting the level of service provided. Accurate coding and documentation are essential for proper reimbursement.

Who is Medical Bill Gurus?

Medical Bill Gurus is a medical billing company led by President Daniel Lynch. They specialize in providing medical billing services for healthcare providers, assisting with the coding, billing, and reimbursement process.

Why is accurate coding important?

What is a level 3 ER visit?

When a patient presents with moderate severity problems in the emergency department, it is typically categorized as a level 3 ER visit. The 99283 CPT code is commonly assigned to these visits.

What are the coding reminder and HIPAA rules to follow?

All coding and reimbursement processes are subject to changes, updates, and other requirements of coding rules and guidelines. It is important to stay up to date with coding changes and follow the HIPAA rules governing medical code sets.

How can I contact Medical Bill Gurus?

If you have any questions or need assistance with medical billing services, you can contact Medical Bill Gurus’ provider services at (651) 662-5200 or toll-free at 1-800-262-0820.

What are the Medicare guidelines for the 99283 CPT code?

Medicare follows specific guidelines for the 99283 CPT code. Reimbursement rates and documentation requirements may vary for Medicare patients. It is important to adhere to their guidelines when coding and billing for Medicare.

What are the reimbursement rates for the 99283 CPT code?

The reimbursement rates for the 99283 CPT code may vary depending on the payer and the geographic location. Medicare sets national facility and non-facility total payment rates for this code. It is important to check specific reimbursement rates for each payer.

Does the concept of global days apply to the 99283 CPT code?

No, the concept of global days does not apply to the 99283 CPT code. ER visits are typically standalone services and are not subject to global periods.

What bundled services are included in the 99283 CPT code?

The 99283 CPT code has bundled services that are included in the reporting of this code. These bundled services should not be reported separately when the main code, 99283, is used.

Are there any related CPT codes for emergency department visits?

Yes, there are several related CPT codes that healthcare providers should be aware of when coding for emergency department visits. These codes include different levels of visits, procedures, and counseling services.

What is the significance of understanding the 99283 CPT code?

Understanding the 99283 CPT code is essential for accurate coding and billing of emergency department visits. Medical Bill Gurus offers medical billing services to assist healthcare providers in optimizing their revenue and navigating the coding and reimbursement process.

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Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions.

KEITH W. MILLETTE, MD, FAAFP, RPH

Fam Pract Manag. 2021;28(1):27-33

Author disclosure: no relevant financial affiliations disclosed.

Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. It can result in $30,000 or more in lost revenue in a year, depending on practice volume. Some doctors choose to report a level 3 instead of a level 4 because of fear of over-coding. 1 Some do level 4 work but their documentation is lacking and doesn't support a level 4 code. But the most common reason I've seen for under-coding level 4 visits is that the coding criteria are complex and time-consuming.

“Coding is complicated and boring,” I often hear physicians say. “I have better things to do, like take care of my patients.”

New rules for coding and documenting outpatient E/M office visits should simplify things, clear up confusion, and help you code more confidently and accurately.

The rules, which took effect Jan. 1, are the most significant changes to E/M coding since 1997 (for more details, see “ Countdown to the E/M Coding Changes ” in the September/October 2020 issue of FPM ). Coding for outpatient E/M office visits is now based solely on either the level of medical decision making (MDM) required or the total time you spend on the visit on the date of service. (See “ E/M coding changes series .”) The history and exam components are no longer used for coding purposes. (Note: these changes apply only to regular office visits and not to nursing home or hospital E/M visits.)

The 2021 E/M coding changes should help ensure you're not leaving money on the table, especially when it comes to coding level 4 visits, which is not as straightforward as coding other levels.

Doing level 4 evaluation and management (E/M) work but coding it as a level 3 office visit is a common mistake that can cost a family physician thousands of dollars each year.

Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement.

Answering three basic questions can help you identify whether you've performed a level 4 visit.

E/M CODING CHANGES SERIES

September/October 2020 — Countdown to the E/M Coding Changes

November/December 2020 — The 2021 Office Visit Coding Changes: Putting the Pieces Together

January/February 2021 — Coding Level 4 Office Visits Using the New E/M Guidelines

CODING LEVEL 4 VISITS: THE BASICS

These are the basic parameters for coding a level 4 visit based on total time or MDM under the new rules.

Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. This includes time spent reviewing the patient's chart before the visit, face-to-face time during the visit, and time spent after the visit documenting the encounter. It may also include discussing the patient's care with other health professionals or family members, calling the patient later in the day, or ordering medications, studies, procedures, or referrals, as long as those actions happen before midnight on the date of service. Total time does not include time spent performing separately billed procedures or time spent by your nurse or other office staff caring for the patient.

The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45–59 minutes.

Many EHRs have time calculators that will show the amount of time you have had the patient's chart open. This will help you keep track of time while you're reviewing the chart before the visit, performing the exam (if you always open the chart at the beginning of the visit and close it at the end of the encounter), and making notes after the visit. It will be less helpful for physicians who open the computer only when needed during the patient visit.

Documentation of total time is fairly straightforward: just note how much time you spent on the visit that day. You aren't required to break down how much time you spent before, during, and after the visit, though that may be helpful supportive detail in the event of an audit. You may want to include a short definition of total time so that patients who read their notes don't confuse it with face-to-face time and think, “My doctor only spent 20 minutes with me, not the 40 minutes listed here.” For example, your documentation could say, “Total time: 40 minutes. This includes time spent with the patient during the visit as well as time spent before and after the visit reviewing the chart, documenting the encounter, making phone calls, reviewing studies, etc.” In addition to preventing misunderstandings, this gives patients a better idea of all the time we spend on them outside of the actual visit. Another way to accomplish it without “note bloat” is to have a pop-up message with this information that appears in the EHR whenever patients access their notes.

Medical decision making is still made up of three elements: problems, data, and risk. But the definitions have changed somewhat (see “ CPT E/M office revisions: level of medical decision making ”). The overall level of the visit is determined by the highest levels met in at least two of those three elements. That means that for an outpatient E/M office visit to be coded as a level 4 (for new or established patients), you need at least two of the three elements to reach the “moderate” category — moderate number and complexity of problems addressed; moderate amount and/or complexity of data to be reviewed and analyzed; or moderate risk of complications and/or morbidity or mortality of patient management. An important difference between coding based on MDM versus total time is that you may count MDM that occurs outside of the date of service (e.g., data reviewed or ordered the day after the patient's visit).

To make this simpler, let's substitute “level 4” for the term “moderate” as we take a look at what qualifies in each category (problems, data, and risk).

Level 4 problems include the following:

One unstable chronic illness (for coding purposes “unstable” includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal),

Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia),

One acute complicated injury (e.g., concussion),

One new problem with uncertain prognosis (e.g., breast lump).

Level 4 data includes the following:

One x-ray or electrocardiogram (ECG) interpreted by you,

Discussion of the patient's management or test results with an external physician (one from a different medical group or different specialty/subspecialty),

A total of three points, earned as follows: a) One point for each unique test ordered or reviewed (panels count as one point each; you cannot count labs you order and perform in-office yourself), b) One point for reviewing note(s) from each external source, and c) One point for using an independent historian.

Level 4 risk includes the following:

Prescription drug management, which includes ordering, changing, stopping, refilling, or deciding to continue a prescription medication (as long as the physician documents evaluation of the condition for which the medication is being managed),

The presence of social determinants of health (lack of money, food, or housing) that significantly limit a patient's diagnosis or treatment,

Decision about major elective surgery without identified risk factors for patient or procedure,

Decision about minor surgery with identified risk factors for patient or procedure.

IDENTIFYING LEVEL 4 VISITS IN THREE QUESTIONS

Here are three questions you can ask yourself to quickly determine whether you've just performed a level 4 visit:

Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? If so, then you're done. Code it as a level 4 using total time.

Did you see the patient for a level 4 problem and either order/review level 4 data or manage level 4 risk? If so, then code it as a level 4 using MDM.

Did you order/review level 4 data and manage level 4 risk? If so, code it as a level 4 using MDM.

Another way to simplify coding level 4 visits is to recognize that ordering labs, x-rays, ECGs, and medications (prescription drug management) often signals level 4 work, while using independent historians, discussing care/studies with external physicians, and providing care limited by social determinants of health are not used as often to code level 4 visits. Therefore, questions 2 and 3 could be rephrased or shortened as follows:

2. Did you see the patient for a level 4 problem and either prescribe a medication, interpret an x-ray (or ECG), or order/review three tests?

3. Did you prescribe a medication and either interpret an x-ray (or ECG) or order/review three tests?

OFFICE VISIT EXAMPLES

Now let's look at three examples of level 4 office visits, documented with the usual SOAP (subjective, objective, assessment, and plan) note. See if you can identify why each is a level 4 before you get to the explanation.

Subjective: 44 yo female presents with 3 day hx of dysuria, frequency, urgency, L mid back pain, fever, chills, and nausea. Has prior hx of UTIs. No hx of pyelo. No hx of resistant infections. Able to keep food down .

Objective: T 100.2, P 96, R 18, BP 110/70. Pt looks ill but not toxic .

EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: Benign. NECK: Benign. No cervical adenopathy. HEART: S1 and S2 w/o murmurs. LUNGS: Clear. Breathing is nonlabored. ABDOMEN: soft, nontender, moderate L CVA tenderness. EXTREMITIES no edema .

Laboratory: UA – TNTC, WBCs – 4+ bacteria .

Assessment/Plan: Pyelonephritis N12. Discussed acute pyelo, also ways to prevent bladder infections. Handout given. Push fluids. Discussed fever and pain control. Cipro 500 mg po bid x 7 days with appropriate precautions. RTC 72 hours, RTC or ER sooner if red flags occur .

Explanation: The total time for this visit was 25 minutes (in the range of a level 3 visit), so it can't be coded as a level 4 using total time. The time also was not documented in the note, which would be required to support coding based on total time. However, here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: acute illness with systemic symptoms.

Was level 4 data ordered/reviewed? No: two lab tests reviewed (three are required).

Was level 4 risk managed? Yes: prescription drug management.

Two out of three criteria meet the requirements for a level 4, so code it as a level 4.

Subjective: 23 y/o female presents for recheck of depression, also complaining of sore throat and ankle sprain .

Counseling going well. Started on sertraline 50 mg 4 months ago. No new stressors. Pt denies depressed mood, insomnia, anorexia, loss of pleasure, suicidal ideation, poor concentration, or irritability. Anxiety is also well controlled .

Has 2 day hx of L lateral ankle pain. Tripped over dog and turned ankle in. Pt able to walk now with mild limp .

Has a 3 day hx of sore throat, fever, and fatigue. Denies other symptoms .

Objective: T 100.4, P 88, R 14, BP 125/70. Pt is NAD, affect is bright, eye contact is good. EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: tonsils 2+ red s exudate. NECK: Benign. No cervical adenopathy. HEART: RRR. LUNGS: Clear. Bilateral ankle exam: L ant drawer is negative, inversion testing on L causes pain, focal mild tenderness and swelling just below L lat malleolus .

Laboratory: strep screen – negative, strep culture – pending .

Assessment/Plan: Depression with anxiety F41.8 well controlled. Sertraline 50 mg refilled. Continue counseling. Discussed depression .

Tonsillitis J03.90. Strep screen neg. Discussed symptomatic measures. Will call if strep culture is positive .

Sprain left ankle, initial encounter S93.492A, is mild and improving. Discussed RICE protocol and NSAIDS if needed .

RTC 2 mo to recheck depression. Call or RTC sooner if problems or concerns develop .

Total time: 35 minutes. This includes time spent with the patient, but also time spent before the visit reviewing the chart and time after the visit documenting the visit, etc .

Explanation: The total time for this visit (35 minutes) is in the range of a level 4 (30–39 minutes), so a physician could code it as a level 4 using total time. However, here's the breakdown for MDM:

Was there a level 4 problem? No: One stable chronic illness, one acute uncomplicated illness, and one acute uncomplicated injury.

Was level 4 data ordered/reviewed? No: two lab tests.

This visit only meets one out of three criteria, so it can't be coded as a level 4 based on MDM. But because the physician has documented that the visit met the criteria for a level 4 based on total time, it can be coded as a level 4.

Subjective: 47 y/o male presents for a BP recheck. His home blood pressures have been averaging 155/95. He denies chest pain, fast heart rate, headache, flushing, or nose-bleeds. Feels good. Taking losartan every day. Watches his wt and exercises .

Objective: T 97.2, P 72, R 16, BP 160/95. NAD.

EYES: Fundi nl. PERRLA. TMs: nl .

PHARYNX: nl. NECK: Benign. Thyroid is not enlarged. HEART: S1 and S2 no murmurs. LUNGS: Clear. ABDOMEN: No masses or organomegaly. EXTREMITIES: no edema .

Assessment/Plan: Essential hypertension I10. Increase losartan to 100 mg per day. Check BP 3 times a wk, avoid salt, continue to limit alcohol to 2 drinks a day or less. RTC for BP check in 3 wks, sooner if problems arise .

Explanation: Total time for this visit was 20 minutes (but not documented in note). That is in the range of a level 3 visit, not a level 4.

Here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: One chronic, uncontrolled illness.

Was level 4 data reviewed/ordered? No: No tests were ordered.

Was level 4 risk managed? Yes: Prescription drug management.

Two out of three criteria were met, so code it as a level 4.

(Templates to help code visits based on total time or MDM are available with “ Countdown to the E/M Coding Changes ,” FPM September/October 2020.)

HOW DOES YOUR LEVEL 4 CODING COMPARE?

Comparing your coding with national averages is a good way to gauge where you stand in terms of getting the reimbursements you deserve. The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare patients). 2

That's a good benchmark. But all practices are different, and some coding variation is normal. In general, doctors with more elderly patients usually have a higher percentage of level 4 visits. Doctors who address fewer problems per visit, have a high patient volume, or have a younger panel tend to have a lower percentage of level 4 visits.

Coding should be easier with the removal of the history and exam components, allowing us to focus more on treating our patients. By using the three questions presented in this article, as well as the patient examples, you should be able to more confidently code level 4 visits and make sure you're getting paid for the amount of work you're doing.

Hill E. How to get all the 99214s you deserve. Fam Pract Manag . 2003;10(9):31-36.

Marting R. 99213 or 99214? Three tips for navigating the coding conundrum. Fam Pract Manag . 2018;25(4):5-10.

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