EM Coding Alert

Here’s why it doesn’t really matter how long an ED E/M lasts.

Coders who find themselves reporting emergency department (ED) E/M codes must make sure that they know the differences between 99281-99285 and office E/Ms.

We asked some ED coding experts about some of the assumptions people might make about ED E/M services. Check out what they had to say about what’s truth — and what’s myth— when reporting codes for ED E/M services.

Myth: Time can be a factor when deciding ED E/M level

Truth: You choose from ED E/M codes 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) based on the three key components of the encounter, regardless of total encounter time, says Joshua Tepperberg, CPC, senior coding analyst at caduceus inc., in Jersey City, NJ.

This fact could be confusing to coders, as some ED visits might appear to merit higher-level codes based on total encounter time.

The difference is the nature of the presenting problem (NOPP), an unofficial “fourth component” of ED E/M codes 99281-99285. NOPP makes it impossible to code above the encounter’s medical necessity regardless of encounter time, tests run, x-rays taken, etc. Just as all services must be medically necessary, the condition must warrant the services, the additional time, the extended care and observations inherent in the ED E/M code.

Example: In the ED, a patient could have comorbidities that hinder the current acute condition that the physician must also take time to address. This might take more time, but it doesn’t necessarily mean that it will up the ED E/M level.

“Even if a chart is overdocumented and the documentation fulfills the criteria for a 99285, not all presenting problems justify this code,” reports Jeff Weintraub, MD, FAAEM, practicing emergency physician and finance director for the emergency physicians at Norwalk Hospital in Norwalk, Conn.

Weintraub is also a fellow of American Academy of Emergency Medicine (AAEM).

Example: The ED physician treats a patient with a badly bruised toe; the physician orders an x-ray and prescribes pain medication with no other complicating acute issue. This chart, either due to the length of the encounter or the amount of physician actions, might appear to allow for 99285 coding. “But the NOPP certainly doesn’t allow for this” level of coding for bruised toe treatment in the ED, Weintraub continues.

Myth: You can’t code 2 ED E/M encounters for the same patient on the same day

Truth: You can “absolutely” report two ED E/M codes for the same patient on the same date if the situation allows, confirms Weintraub.

Seeing the same patient twice on the same day is “fairly common with respiratory cases, flu cases and substance abuse cases, to name a few,” relays Tepperberg. Patients might also report for two separate problems in the same day.

Example: A patient reports to the ED in the morning for a fever and nausea and vomiting; the physician performs a level-three ED E/M. That evening, the same patient arrives again at the ED after falling on her sidewalk and down a few steps, causing severe abrasions and a possible broken bone. Notes for the second visit indicate a level-four ED E/M.

In this instance, you’d report 99283 (… an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) for the first visit and 99284 (… a detailed history; a detailed examination; and medical decision making of moderate complexity) for the second visit.  

Because these are two separate encounters that address two separate issues, some payers will allow you to code for both services without a modifier; others, however, will require you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the second ED E/M. Check with your payer if you are unsure about using modifier 25 on multiple ED E/M claims.

Caveat: Some payers may deny the second claim if both encounter are for the same diagnosis, “but based on the principle that every presentation to the ED is a new and separate visit, if the patient presents twice you can code them both,” explains Weintraub. If the claim doesn’t pass muster, be ready to appeal for your rightful reimbursement.

Best bet: Be sure to indicate to the payer that each ED visit on the same date is for a separate incident — even if both incidents involve the same diagnoses. Thorough and complete notes on both encounters will be essential to helping ease the claim through to proper adjudication.