ED Coding and Reimbursement Alert

Reviewed on May 29, 2015   Latest on Accurate Use of CPT Codes 99283 and 99284 from Codify's E/D Coder:   Definition: An emergency service (ED) is performed in the emergency department. CPT code range 99281-99285 are applied for either a new or returning patient. Services that are performed outside of the emergency department (in an office or outpatient setting) cannot be billed with ED codes because they are reserved for hospital-based facilities that are open 24 hours a day. To choose which level is appropriate, at least three or more required key components (History, Exam and Medical Decision-Making) must be documented.
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CPT codes 99282 and 99283 are chosen based upon the level of decision making that was required. Conversely, CPT codes 99284 and 99285... ...to read the full article and understand the accurate usage of 99283 and 99284, subscribe to Codify's Emergency Medicine Coder.

Take a FREE Trial and use the tool before you subscribe.     In most EDs, the Level 3 and Level 4 evaluation and management (E/M) codes are the ones most commonly reported. However, the line between a Level 3 service and that of a Level 4 can sometimes be hard to distinguish.

The medical decision-making required for both codes is the same: moderate complexity. The technical difference between the two levels of service lies mainly in the level of history taken and the level of physical examination performed by the physician. CPT® 99283 requires the performance of an expanded problem-focused history and physical while CPT® 99284 requires a detailed history and physical.

However many coding and billing experts are warning that just because the physician documents a more extensive history and physical than is required for a 99283, the service provided does not merit reporting 99284.

I have done chart audits on Level 3 and Level 4 visits because the medical decision-making is the same, and I have seen some that I didn’t think used very good judgment, says Jackie Davis president of Term Billing, an emergency medicine billing company in Austin, TX. For example I saw a lot of otitis media (infection of the middle ear) coded at a Level 4. No matter what the guidelines are you still have to use common sense and integrity. Treatment of otitis media is rarely going to warrant a Level 4, maybe with a complication such as bronchitis, but almost never just otitis media by itself.

Requirements of History

The first component of any of the emergency service E/M levels is the level of history taken.

According to the CPT® documentation guidelines both the 1995 and 1997 [...]