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

cpt ed visit

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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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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Topics: 2023 guidelines Coding CPT guidelines Practice Management Reimbursement & Coding

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March 5, 2024

Emergency Department Visits

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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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Who Uses These Codes?

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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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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Emergency Department Visits Diagnoses Medical Coding Guidelines

Q: Are Emergency Department visits diagnoses which state “suspected,” “presumed,” etc., to be coded following the inpatient or outpatient guidelines? That is, are coders to follow inpatient guidelines of “confirmed” if the patient is admitted through the ED to Observation/Inpatient status and use the outpatient guidelines of “not confirmed” if the patient is discharged from ED to home? Can you please give me directions on this?

A: That is a great question. When we take a look at this, a couple of things to remember, the question confused a few things: you got to remember what areas of the hospital are considered outpatient hospital departments. Both the Emergency room and Observation status, even if the patient is “admitted” to observation, that is still considered an outpatient part of the hospital. Those outpatient departments are required to follow the Section IV guidelines in the ICD-10 manual . Those are the guidelines for Diagnostic Coding and Report Guidelines for Outpatient Service .

According to that, most facilities – just to give you an idea of what happens in most facilities – if a patient presents to the emergency room, those emergency room charges are entered into the system. And guess what, they actually get put into the same system, if you will, as the charges that are used to generate your inpatient claim. If we have a patient come into the ER whether they’re discharged and sent home or admitted to the inpatient facility, they get put in to the hospital billing system, and so do the inpatient charges that the patient is admitted.

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When the claim is generated, they then look to see what place of service did that patient wind up in to determine which rules do we need to follow. If they wind up in the inpatient environment, they were admitted for a full hospitalization, the claim that’s generated is going to utilize the inpatient diagnosis, quite frankly. It is going to code for all of the different pieces that it needs to.

As an ER coder or an ED coder, what you need to do is remember that regardless of where the patient winds up, your services is part of the hospital outpatient department and you have to code those accordingly, so you’re going to follow those Section IV guidelines.

When it comes to uncertain diagnoses, which is what this question started with: What do I do with those probable, suspected, likely, rule out, all of those? The guidelines are specific. What I did was I pasted in a picture of the guidelines directly from my coding manual, that’s why they’re all marked up and then I typed up the same thing. In case it came out blurry or you had trouble reading it, you can actually see it typed as well.

Emergency Department Visits Diagnoses Medical Coding Guidelines

Instead, what you do is you code what the highest degree of certainty was that the provider knew during that ER visit, what did they know? Maybe they only knew the patient had abdominal pain, that’s all you could code. They haven’t figured out yet what else was going on with the patient, so you’re going to code whatever it is you know. That can be signs and symptoms, that can be abnormal test results, it could be any other reason for the visit if you don’t have a definitive diagnosis. That’s if you’re coding for the hospital outpatient department like the emergency room.

What do you do if you’re the inpatient coder? We ask this question from an ER perspective, but what happens if I’m an inpatient coder and I’m coding for the facility charges inside the hospital? Quick designation I want to make, a lot of people confused inpatient and outpatient and they think, “Oh, outpatient is the doctor, inpatient is the hospital.” No. We’re talking about different places of service.

The physician services, those are what we call our professional services, our pro fees, and that doctor can provide services on either place. They can work in their office or they can work in the hospital. Either way, they are considered an outpatient entity, they have to follow the outpatient rules because we’re not billing, they’re not billing for the hospital.

The hospital has two different sets of rules, either we have the outpatient departments like we just talked about with the ER, or we’re billing for the inpatient services, the full admission where we’re billing for room and board and lights and all of the equipment that we use and everything else. Well, if you’re an inpatient coder billing for the facility, your roles are different. Instead of Section IV, which is what the outpatient and the physician’s follow, in the inpatient hospital environment you follow the Section II guidelines, and those tell you what to do.

They say specifically under Section II.H, it says Uncertain Diagnosis. If you’re coding for the inpatient hospital facility, you are going to take what the diagnosis says at the time of discharge. Not at the time they’re admitted, but right when we send them home, that discharge summary.

Emergency Department Visits Diagnoses Medical Coding Guidelines

The reason for this is, when we’re billing in the inpatient facility environment, we are billing for the services that it took to rule in or rule out that diagnosis. It doesn’t matter whether the patient has appendicitis or not. If we’re trying to figure out whether they have it, we’re going to use the same amount of resources to rule it in as we would to rule it out. That’s the only reason this differ.

The other reason that they differ, if I’m billing for the facility, I can assign a diagnosis that says “rule out appendicitis,” I can call it appendicitis and it never attaches to my patient. It simply says we used all of the services that we needed to rule out appendicitis. If I attach it from an outpatient or a physician perspective, that diagnosis attaches to the patient because we’ve said it’s a confirmed diagnosis, that’s what the guideline says. If I were to assign something that the patient did not actually have, I was still trying to figure out, rule it out, I could wind up putting something they never had on their record and it’s very, very difficult to then get that removed and that creates all sorts of problems for the patient down the road. Worst case scenario, we accidentally assign a cancer diagnosis or heart attack diagnosis to a patient who never had either. That could prevent them from getting life insurance, all sorts of issues.

That’s why you need to remember when you’re coding for these, if I’m coding for the inpatient facility, I follow the Section II rule that says: “Hey! I can code those ‘probable,’ ‘suspected,’ ‘likely,’ ‘rule out.’” If I’m coding for the outpatient hospital or I’m coding for the physician, oh no those attached to the patient and I follow the Section IV guidelines that say I cannot use those. If you’re an ED coder or an ER coder, your hospital outpatient facility and you got to remember when you got a probable, a suspected, a likely or any kind of uncertain diagnosis, we cannot code for those. I think that wraps that one up.

Laureen: I just wanted to say, too, for people that are seeing Chandra’s notes, many people are familiar with CCO’s BHAT® system , this is Chandra’s version of annotation; and so, the same way that we make available my entire CPT manual, to see all of the notes, we’re doing the same with Chandra’s ICD-10 manual. That’s very valuable, so if you’re a full student of ours, you get access to that. I just wanted to throw that in there and her handwriting is a lot neater than mine.

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Coding Ahead

(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. 

99285 cpt code

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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cpt ed visit

Time and Medical Decision Making Levels for Evaluation and Management Services

Find the total time and medical decision making levels for a variety of E/M codes and service areas. 

Jump to a Service Table: Office or Other Outpatient | Inpatient and Observation Care | Consultation | Emergency Department | Nursing Facility | Home or Residence

Have questions about how and when to use total time or mdm, office or other outpatient services.

Total time and MDM do not apply to 99211. CPT code 99211 is intended for the evaluation and management of a patient that may not require the presence of a physician or other QHP.

Inpatient and Observation Care Services

The observation CPT codes (99217, 99218, 99219, 99220, 99224, 99225, 99226) have been deleted and merged into the existing hospital care CPT codes.

Initial vs. subsequent is determined based on whether the patient has received any professional services from the physician or other QHP or another physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice during the stay. This is like the new vs. established patient definitions, except the determining factor is related to the stay rather than the past three years. 

*Total time within 3 calendar days of the encounter.

Time includes total time on the date of the encounter.  

Hospital Inpatient or Observation Care Services require that the patient be admitted and discharged on the same date of service and the stay must be at least eight hours. Only the physician or QHP who performs both the initial and discharge service may report these services. When a patient receives hospital inpatient or observation care services for fewer than eight hours, use the initial hospital inpatient or observation care codes (CPT codes 99221-99223). 

Consultation Services

Most of the guidelines for the consultation codes remain the same. Code descriptors have been edited to reflect the revised MDM and time requirements. Note: Medicare does not cover consultation codes. 

Emergency Department Services

Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits. 

MDM does not apply to 99281. CPT 99281 is intended for the evaluation and management of a patient that may not require the presence of a physician or other QHP. 

Nursing Facility Services

*Total time 1 day before visit + date of visit + 3 days after 

Nursing facility discharge services require a face-to-face encounter with the patient and/or family/caregiver that may be performed on a date prior to the date the patient leaves the facility. The level of service should be selected based on the total time on the date of the face-to-face discharge management encounter. 

The CPT code for annual nursing facility assessment (CPT code 99318) has been deleted. These services can be reported using the subsequent nursing facility care services (CPT codes 99307-99310) or Medicare G codes. 

*Total time 1 day before visit + date of visit + 3 days after  The CPT Panel established a high-level MDM type specific to initial nursing facility care by the principal physician or other QHP that takes into account the number and complexity of problems addressed. This type is: "Multiple morbidities requiring intensive management: A set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations. The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital.”  A principal physician is sometimes referred to as the admitting physician and is the individual who oversees the patient’s care. This is different from other physicians or other QHPs who may be furnishing specialty care.  Initial vs. subsequent is determined based on whether the patient has received any professional services from the physician or other QHP or another physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice during the stay. This is like the new vs. established patient definitions, except the determining factor is related to the stay rather than the past three years. 

Home or Residence Services

The domiciliary or rest home CPT codes (99334-99340) have been deleted and merged with the existing home visit CPT codes (99341-99350). 

*Total time 3 days before visit + date of visit + 7 days after 

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  1. Coding Inpatient and Observation Visits in 2023

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  2. 2023 AMA CPT Documentation Guideline Changes for ED E/M Codes 99281

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  3. CPT® E/M Office Visit changes: How did we get here and what changes can you expect?

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  1. Emergency Department Nurses Week

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COMMENTS

  1. Emergency CPT

    Procedure code and Descripiton 99281 (CPT G0380) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided…

  2. 2023 Emergency Department Evaluation and Management Guidelines

    99282 - Emergency department visit for the evaluation and management of a patient, ... or rule-out diagnoses because these conditions cannot be used for ICD-10 coding in the emergency department, other outpatient settings. However, these rule-out conditions illustrate the significance of the complexity of problems addressed and justify the work ...

  3. 2023 AMA CPT Documentation Guideline Changes for ED E/M Codes ...

    These changes reflect a once in a generation restructuring of the guidelines for choosing a level of ED E/M visit impacting roughly 85% 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.

  4. Coding and Billing Guidelines for Emergency Department

    Coding & Billing Guidelines. Emergency Department (ED) Evaluation and Management (E/M) codes are typically reported per day and do not differentiate between new or established patients. There are 5 levels of emergency department services represented by CPT codes 99281 - 99285. The ED codes require the level of Medical Decision Making (MDM) to ...

  5. Approach to Emergency Department Coding FAQ

    Below is a partial listing of some of the CPT codes commonly used by emergency physicians. 1. Emergency Department Evaluation & Management (E/M) Codes (99281-99285) This code set was developed in 1992 for use by emergency medicine physicians. Five (5) different levels of service are used depending on the nature of the presenting complaint to ...

  6. Coding for hospital admission, consultations, and emergency department

    Cpt initial hospital care Cpt ed visit Cpt outpatient consultation 99221 2.84 99281 0.60 99241 1.37 99282 1.18 99242 2.58 99222 3.87 99283 1.76 99243 3.52 99284 3.36 99244 5.20 99223 5.30 99285 4.93 99245 6.36 tABL 4.e 2013 totAL iNitiAL HosPitAL, iNPAtieNt AND outPAtieNt CoNsuLtAtioN FACiLity AND NoNFACiLity rvus

  7. 2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

    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 ...

  8. Emergency Department Visits

    Definition 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

  9. Emergency Department Services CPT ® Code range 99281- 99288

    The Current Procedural Terminology (CPT) code range for Emergency Department Services 99281-99288 is a medical code set maintained by the American Med. Select. Code Sets; Indexes; Code Sets and Indexes; ... 30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) A ...

  10. Visit the Facility Side of ED Coding

    The facility coder must know which codes they are required to assign to avoid omission or duplication of reimbursable services. Acuity Levels in the ED. ED facility evaluation and management (E/M) levels are assigned using CPT® ED services codes 99281-99285 and, in some instances, critical care codes 99291-99292.

  11. Code 99284 Details

    CPT®Code 99284 Details. Upcoming and Historical Information Change Type Change Date Previous Descriptor Code Changed 01-01-2023 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.

  12. Emergency Department Visits

    99283 (G0382) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical-decision making. Any interventions from above, plus any below: Receipt if EMS/Ambulance patient. Heparin/saline lock. One Nebulizer treatment.

  13. PDF Emergency department visit place of service restriction

    Plus (Blue Cross) will restrict the emergency department visit evaluation and management codes to the emergency place of service (23), in accordance with CPT coding rules. Per CPT definition, the codes 99281-99285 are for reporting evaluation and management services in the emergency department.

  14. PDF Under the OPPS, which part of a hospital emergency department is

    Hospitals report Type B emergency department visits using HCPCS codes G0380-G0384. Hospitals report hospital outpatient clinic visits using HCPCS codes 99201- ... hospital's own coding guidelines, the patient must be a registered outpatient being treated in a Type A or Type B emergency department. The hospital's own coding guidelines must

  15. ED Facility Level Coding Guidelines

    The ACEP facility coding model provides an easy to use methodology for assigning visit levels in an Emergency Department (ED). There are three columns in the guidelines. The far left column indicates the facility codes and corresponding APC levels which are justified by the "Possible Interventions" listed in the middle column. The far right ...

  16. Coding for Emergency Department Visits

    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 ...

  17. Outpatient E/M Coding Simplified

    The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. These are added in 15-minute increments in addition to codes 99205 or 99215.

  18. Coding ED E/M in 2023

    Attendees at AAPC's AUDITCON, Nov. 3-4, 2022, came loaded with questions about the coding and guideline changes for evaluation and management (E/M) services in CPT® 2023. The conference offered several sessions on the subject, including the ED session, "Changes in 2023: Emergency Department," presented by AAPC Chief Product Officer ...

  19. Emergency Department Visits Diagnoses Medical Coding Guidelines

    What those guidelines say is if you're coding for the hospital outpatient department, you do not code for any diagnoses that is documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or anything else that indicate uncertainty; so no "probable," "likely," "suspected," anything ...

  20. (2023) CPT Code 99285

    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 ...

  21. PDF Coding Reference Guide Measure Year 2024 Follow-Up After Emergency

    days) of an Emergency Department (ED) visit. Notes • Members must be 18 years of age or older as of the ED visit date • The ED visit must occur on or between January 1, 2024, and December 24, 2024 ... Case Management Visits CPT: 99366 HCPCS: T1016, T1017, T2022, T2023 SNOMED: 386230005, 416341003, 425604002 Complex Care Management Services CPT:

  22. An ED Visit and Admission on the Same Day? Here's How

    The pre-admission examination can be extensive, lasting an hour or more in some cases. But under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 15047 [G]), the surgeon can report only an initial hospital care code (99221-99223) if the ED visit and subsequent hospital admission occur on the same day.

  23. Time and Medical Decision Making Levels for Evaluation and ...

    The domiciliary or rest home CPT codes (99334-99340) have been deleted and merged with the existing home visit CPT codes (99341-99350). Home or Residence Services - New Patient Code

  24. GitHub Copilot overview

    Congratulations, you've now used artificial intelligence to enhance your coding! You can read more about Copilot and how to use it in VS Code in the GitHub Copilot documentation . Or check out the VS Code Copilot Series on YouTube, where you can find more introductory content and programming-specific videos for using Copilot with Python , C# ...

  25. Payment for an ED Visit and a Hospital Admit on the Same Day?

    The pre-admission examination can be extensive, lasting an hour or more in some cases. Under most payers' guidelines (and as explicitly stated in the Medicare Carriers Manual, section 155047 [G]), however, the surgeon can report only an initial hospital care code (99221-99223) if the ED visit and subsequent hospital admission occur on the same ...