Correctly Apply 99285 Acuity Caveat to Optimize E/M Coding
Published on Fri Jan 01, 1999
Latest on Accurate Usage of CPT Code 99285 from Codify's E/D Coder: Salvage Your 99285 Claims With This Can't-Miss Caveat A patient reports to the ED with a severe illness or injury. Encounter notes indicate that the physician provided a comprehensive exam and high-level medical decision making (MDM) ... but the history documentation is limited. What do you do? The level five ED acuity caveat, a very specific coding exception, could help you code this service as a 99285 " provided the encounter notes reflect a level-five exam and MDM. Before using the ED caveat, however, you need to know when you can " and can't " invoke this inception. If you employ the ED caveat improperly, auditors are likely to come beating at your door. Use these ED caveat do's and don'ts to guide your ED exception coding... ...to read the full article and understand the accurate usage of 99285, subscribe to Codify's Emergency Medicine Coder.
Take a FREE Trial Today. The emergency department services code 99285 is the highest level emergency E/M code. It is almost always reserved for treating patients with life-threatening illnesses or injuries.
Like the level five office and outpatient E/M codes (99205, new patient, and 99215, established patient) the 99285 code requires the three components of a comprehensive history, comprehensive examination, and medical decision-making of high complexity.
However, the CPT definition of 99285 includes an interesting phrase: Emergency department visit for the evaluation and management of a patient which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and mental status.
The words in boldface above constitute what is known as the emergency department caveat or acuity caveat. This phrase serves as recognition in CPT that treating a patient suffering from an immediate life-threatening emergency sometimes makes the completion of a comprehensive history and examination very difficult and in many cases clinically inappropriate says Todd Thomas CPC CCS-P president of the Oklahoma City OK chapter of the American Academy of Professional Coders and principal of Thomas and Associates an emergency medicine reimbursement consulting firm also based in that city.
If any of the elements required are limited because the urgency of the patients condition is such that to obtain a complete history or exam would not be appropriate the physician is still able to bill a level five when the situation warrants it Thomas explains.
Payers Differ on Requirements for Billing
In order to use the caveat the physician should document which of the three components are incomplete due to the patients [...]
