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Guidelines for Emergency Department Evaluation and Management Codes

Guidelines for Emergency Department Evaluation and Management Codes

Guidelines for Emergency Department Evaluation and Management Codes

As per CMS definition, 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 basic requirement for emergency department (ED) is, the facility must be available 24 hours a day. Emergency department (ED) Evaluation and Management (E/M) codes do not differentiate between new or established patients and they are typically reported per day. There are 5 levels of emergency department services represented by CPT codes range 99281 – 99285. The emergency department codes require all three key components (history, examination, and medical decision-making) to be met and documented for the level of service selected.

  • For critical care services provided in the emergency department, see Critical Care guidelines and 99291, 99292. Critical care and emergency department services may both be reported on the same day when after completion of the emergency department service, the condition of the patient changes and critical care services are provided.
  • For evaluation and management services provided to a patient in observation status, see 99221, 99222, 99223 for the initial observation encounter and 99231, 99232, 99233, 99238, 99239 for subsequent or discharge hospital inpatient or observation encounters.
  • For hospital inpatient or observation care services (including admission and discharge services), see 99234, 99235, 99236.
  • To report services when a patient is admitted to a hospital inpatient or observation status, or to a nursing facility in the course of an encounter in another setting, see Initial Hospital Inpatient or Observation Care or Initial Nursing Facility Care.
  • For procedures or services identified by a CPT code that may be separately reported on the same date, use the appropriate CPT code. Use the appropriate modifier(s) to report separately identifiable evaluation and management services and the extent of services provided in a surgical package.
  • If a patient is seen in the emergency department for the convenience of a physician or other qualified health care professional, use office or other outpatient services codes (99202-99215).
  • Note that, the ‘time’ is not a descriptive component for the emergency department levels of evaluation and management services 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.
  • Also note that, in the emergency department, no distinction is made between new and established patients. Evaluation and management services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Applicable CPT Codes

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

Other Emergency Services

In directed emergency care, advanced life support, the physician or other qualified health care professional is located in a hospital emergency or critical care department and is in two-way voice communication with ambulance or rescue personnel outside the hospital. The direction of the performance of necessary medical procedures includes but is not limited to: telemetry of cardiac rhythm; cardiac and/or pulmonary resuscitation; endotracheal or esophageal obturator airway intubation; administration of intravenous fluids and/or administration of intramuscular, intratracheal or subcutaneous drugs; and/or electrical conversion of arrhythmia.

Note that,

The level of service billed must be based on the intervention(s) that are performed in relation to the medical care required by the presenting symptoms and resulting in a diagnosis of the patient. Professional codes are based on complexity and performed work, which includes the “cognitive” effort. Facility codes reflect the volume and intensity of resources used by the facility to provide care. Medical records and documentation may be requested from the provider to support the level of care rendered. The documentation must clearly identify, and support emergency department E/M codes billed. If a denial is appealed, the supporting documentation must be included in the appeal request. Insurance reimbursement will depend upon group or Individual benefit; provider participation agreement; routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity; and mandated or legislatively required criteria.

Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. Our coding team is well-versed in guidelines for emergency department evaluation and management codes. We can assist you in the accurate selection of E/M codes and modifiers. Legion Healthcare Solutions is having extensive experience working with eClincialWorks (ECW), Lytech, Medisoft, AdvancedMD, Kareo, Office Ally, and all major medical billing software. To know more about Emergency Department (ED) coding services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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