ED Coding: Make the Call When Service Level Requirements Overlap

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  • April 1, 2013
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By Ronda Tews, CPC, CHC, CCS-P

Most emergency department (ED) visits are stressful for the patient, but too often they are also stressful for the coder or physician responsible for choosing the evaluation and management (E/M) level to report to the payer. At first glance, choosing a service level shouldn’t be hard: There are only five levels to choose from, with no distinction between new and established patients in the ED, and there are insightful documentation requirements for each ED level in the CPT® codebook. So what’s the problem?
It’s Harder than You Think
Take a closer look at the ED documentation requirements, however, and you’ll see where the difficulty for selecting an E/M level lies:

  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making.


  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Medical decision making of low complexity.


  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Medical decision making of moderate complexity.


  • A detailed history;
  • A detailed examination; and
  • Medical decision making of moderate complexity.


  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of high complexity.

The bold text shows that different codes contain some of the same requirements, which means selecting a level is not always straightforward. Consider also:

  • History of Presenting Illness (HPI) requires one to three elements to be problem focused or expanded problem focused; and four or more elements to be detailed or comprehensive.
  • Examination requires two to seven systems to be expanded problem focused or detailed.
  • Medical decision making (MDM) is challenging when it comes to moderate complexity because this is the requirement for 99283 and 99284.

These overlapping requirements allow for gray areas, making the appropriate ED level choice very challenging. To add to this dilemma, the use of documentation templates in the electronic health record (EHR) is becoming more widespread. To save time, the physician often creates his or her own template for a review of systems (ROS) and physical examination, which are usually comprehensive. Every patient encounter ends up with a comprehensive history and a comprehensive examination, with the final determination of the ED level dependent on MDM.
But remember: Moderate MDM is required for 99283 and 99284.
The American Medical Association’s 2012 CPT® Professional codebook includes the following clinical examples in Appendix C, which may provide some guidance:

  • Emergency department visit for a well-appearing 8-year-old who has a fever, diarrhea, and abdominal cramps, is tolerating oral fluids and is not vomiting.
  • Emergency department visit for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness or memory deficit.


  • Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.
  • Emergency department visit for a patient with flank pain and hematuria.
  • Emergency department visit for a female presenting with lower abdominal pain and a vaginal discharge.

The clinical examples are of little use, however, if you are questioning an ED case that has a comprehensive history, comprehensive exam, and moderate complexity MDM. Unless the example exactly matches your case, you are left to determine the appropriate ED level based solely on your opinion and experience.
If the history and exam are both comprehensive, many coders would lean toward 99284; but keep in mind the templates being used in the EHR, where every patient has a comprehensive history and a comprehensive exam. That would mean 99283 would never be billed.
Tackle the Gray Areas
I have several recommendations to deal with these difficult areas:

  1. Share your concerns with physicians. Show them the clinical examples in CPT® and ask for their input on how a given service might be reported. It’s only appropriate for the physician, whose name is on the claim, to have the final say on what he or she feels is the most appropriate ED level under the circumstances.
  2. Put in place a coding policy to assist coders in determining the most appropriate ED level when “bean counting” isn’t enough. The policy should be as specific as possible, so the coder can determine the number of elements needed for an “expanded problem focused” history and “expanded problem focused” exam when choosing between 99282 and 99283, as well as for moderate complexity MDM when choosing between 99283 and 99284. This will alleviate confusion for the coder and set a baseline for your organization so everyone is on the same page.
  3. Stay away from “one-size-fits-all” guidelines, such as “report 99284 whenever there is a comprehensive history or comprehensive exam.” Determine the appropriate service level on a case-by-case basis.
  4. Lastly, remember that medical necessity, above all else, should drive the clinical process and, by extension, coding and billing. Per the Medicare Claims Processing Manual, chapter 12, section 30.6, paragraph A:

“Medical necessity of a service is THE overarching criterion for payment in addition to the individual requirements of a code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”
Ronda Tews, CPC, CHC, CCS-P, is a senior financial analyst in revenue compliance for Mercy. She conducts E/M audits for all Mercy providers in Oklahoma, and also teaches coding and documentation to physician assistant students at Missouri State University. Ms. Tews has been in the health care industry for over 20 years, and has served as secretary and president of her local AAPC chapter.

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No Responses to “ED Coding: Make the Call When Service Level Requirements Overlap”

  1. Dr Shraddha says:

    I had a dout regarding considering additional work up performed via physician .if patient is transfered by physician can it be considered as additional work up? if pt transfered to rehab etc