ED Coding and Reimbursement Alert

Question: I just started working for a general practice whose physicians see patients in the emergency department (ED) setting at times. I have been told that coding evaluation and management (E/M) services for patients in an ED setting is different than coding for E/Ms that occur in an office/outpatient setting. What are the main differences between ED and office/outpatient E/M coding?

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Answer: The main difference is the codes, which are completely separate. You’ll report ED E/Ms with 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making), while you’ll report office/outpatient E/Ms with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.).

Within the code descriptors, you can see clues as to the differences between the code sets. First, ED E/M codes do not distinguish between new and established patients. You’ll report 99281-99285 “for any new or established patient who presents for treatment in the emergency department,” per CPT^®.

The other difference is the lack of a time component for ED E/Ms, meaning you cannot code an ED E/M based on encounter time. This differs from office/outpatient E/Ms, which all have a time component.

CPT^® reports that you cannot use time as a descriptive component for ED E/Ms 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.”

Chris Boucher, MS, CPC, Senior Development Editor, AAPC