ED Coding and Reimbursement Alert

If you’re looking for a place to start when working to compare your ED’s code utilization against others’, look no further than the national averages from Medicare. Frank Cohen, director of analytics and business intelligence at Doctors Management, shared the averages for each specialty during his Jan. 16 presentation, “Risk-based Auditing: New Tools and Techniques.”

Check out the top five CPT^® codes reported by ED providers in 2019, based on CMS data.

Top-Billed Code: 99285

Code 99285 (Emergency department visit for the evaluation and management of a patient …) is at the top of the list.

This code describes the highest level of ED evaluation and management (excluding critical care), and many insurers are cracking down on high use of the code. CMS issued a comparative billing report on it in 2019, while several Part B MACs have launched reviews of the code. Private payers are also scrutinizing 99285, with UnitedHealthcare (UHC) noting that “many” claims for 99285 did not fulfill the code’s requirements.

“To use CPT^® code 99285 for billing, the presenting problem(s) during an emergency room visit are expected to include the following: medical conditions that are of high severity, are potentially life threatening, and require the immediate attention of a physician,” UHC said in a memo entitled Overuse and Misuse of CPT^® Code 99285.

Keep in mind that you should not just let the patient’s presenting complaint drive your use of 99285. Instead, you should base your code choice on the documentation. For instance you won’t always bill a concussion with 99285 — and on the flip side, there may be occasions when a patient presents with an earache and you end up reporting 99285 because you realize the symptom isn’t a simple earache, but a more complex condition requiring additional attention.

With high copays for the ED imposed by payers and a plethora of urgent care centers in operation (over 10,000 nationwide) the trend is that sicker patients are presenting to emergency departments and over time, lower acuity patients are seeking care in other settings.

Therefore, evaluate your 99285 coding to ensure that it meets the code’s requirements. The one exception is when you invoke the 99285 “acuity caveat” that allows you to defer parts of the history and physical exam “within the constraints imposed by the urgency of the patient’s’ clinical condition and/or mental status.” 

If the patient is too ill or injured to safely do a complete review of systems or physical exam, or perhaps unconscious or demented so as to be unable to provide a history, those elements can be deferred as long as the nature of the presenting problem is of high severity and poses a significant threat to life or physiologic function.

Code 93010 Ranks Second

ED providers logged 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) as their second most-reported code last year, Cohen said. Each payer is likely to have its own regulations on billing this code, but Part B MAC Noridian’s policy states, “An ECG is indicated to diagnose or treat a patient for symptoms, signs, or a history of heart disease; or systemic conditions that affect the heart.”

Therefore, be sure to avoid blanket ECGs — always ensure you have a medically necessary reason to perform them, and that those reasons are clearly reflected in the documentation.

Report Lists 99284 as Third Most-Billed Code

ED visit code 99284 (Emergency department visit for the evaluation and management of a patient …) came in third in terms of reporting frequency during 2019, Cohen said. This code represents a service featuring a detailed history and exam, and moderate complexity medical decision making (MDM).

Some physicians report this code improperly, according to a missive from Part B MAC Palmetto GBA. “Clearly document your clinical perception of the patient’s condition to assure claims are submitted with the correct level of service,” Palmetto said in its memo entitled Errors in Emergency Department Services. “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.”

Therefore, even if a patient has a chronic condition like diabetes, you shouldn’t be counting it toward your risk level unless it impacts the complexity of your MDM significantly, according to the guidelines.

E/M Code 99283 Was Fourth Most-Billed CPT^® Code

Coming in fourth place during 2019 was 99283 (Emergency department visit for the evaluation and management of a patient …), which describes an ED visit with an expanded problem focused history and exam, and MDM of moderate complexity.

Remember that in the ED, you must meet all three components of the code, rather than two out of three, which is what’s required in the outpatient setting. So if you have an expanded problem focused history and moderate MDM, but only a problem focused exam, then you must report 99281 for the visit instead.

Critical Care Ranks Fifth

Critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) was the fifth most-reported code to Medicare by ED providers.

Critical care is another service that auditors keep a close eye on, and the OIG added these codes to its Work Plan last year. “Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient,” the OIG said. “Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient.”

Make sure you only count time toward critical care if the physician is immediately available to the patient, and that your documentation reflects this. In addition, take careful notes that document the time you spent on the patient’s care so you can accurately tally up the time that should go toward your code selection.