Medicare Compliance & Reimbursement

The reporting rules for evaluation and management (E/M) services performed in an emergency department (ED) can be tricky. Not only does your documentation need to be stellar, but you need to know the nuances associated with time and patient status, too, which are different from other E/M service codes.

Why? First, the HHS Office of Inspector General (OIG) recently added Medicare ED E/M services to its audit to-do list. The Work Plan addition is currently one of OIG’s hot topics on the agency’s “What’s Trending” daily list.

When providers perform E/M services in the ED, the CPT^® codes must align with the services performed and match “the health care CPT^® coding system code definition,” cautions Work Plan Active Item W-00-21-35877. “Medicare reimburses physicians based on a patient’s documented needs at the time of a visit.” Plus, medical necessity must be “clearly evident” in the reporting to Medicare, OIG reminds.

“This review will determine whether Medicare payments to providers for emergency department E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements,” explains the Action Item.

Register This Other Potential Problem With These Claims

Remember, the descriptors, and rules, for reporting office/ outpatient E/M codes changed dramatically in 2021. For that reason, coding 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 time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) 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 time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) is very different this year.

However, there’s no difference in ED E/M reporting, which adds another layer of confusion to these codes. Check out the rules that still govern claims with 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. …).

Don’t Worry About Encounter Time

When you report ED E/M services, you cannot use time as a factor in code selection, confirms Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

“Emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is difficult for physicians to provide accurate estimates of the time spent face-to-face with the patient,” explains Falbo.

When choosing an ED E/M code, “the complexity of the care provided is what should be considered in the documentation and, ultimately, in the level selected,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

Rely on 3 Components

Because time isn’t a factor in ED E/M coding, you’re going to have to rely on fulfilling the key components in the descriptors. As the descriptors indicate, there are three components: history, examination, and medical decision making (MDM). These are like the old descriptors for 99202-99215 with one important exception — you need to fulfill all three components at a certain level before choosing a code. There are no ED E/M situations in which two out of three key components is enough to select a code.

Example: Notes indicate that the provider performed an expanded problem-focused history, expanded problem-focused examination, and low-complexity MDM. On the claim, you’d report 99282 (… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. …) because you only achieved low-complexity MDM.

Forget About Patient Status

You’ll also notice that there are no patient designations in the ED E/M codes. The concepts of new and established don’t exist because each ED visit is treated as a completely separate service from any other ED service the patient receives, and a full workup is required each time.

“This is listed specifically in the guidelines. No distinction is made between new and established patients in the emergency department,” stresses Falbo.

The reason for this lack of distinction is that “a patient coming to the ED is not considered new or established,” explains Hauptman. “The condition of the patient is always new to the ED; thus, the patient’s status does not come into play. If the patient has been to that ER for a broken foot and now presents with chest pain, the new issue is what is considered.”

Prolonged Services Coding Doesn’t Factor Into the Equation

As there are no time components in the ED E/M codes, you cannot code for prolonged services in the ED, confirms Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico. “Prolonged services require that an E/M service that includes a typical time must be billed before the prolonged services can be added on and that prolonged service must exceed the typical time in the E/M code by 30 minutes before it can be added.”

Bottom line: Forget about adding +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215])) or +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service)) to your ED E/M service claims, no matter how long the encounter lasted.

CPT^® backs up Witt’s statement. According to CPT^® 2021: “If a time-based add-on code is reported, it can only be used with E/M codes with typical or specified times in their descriptors. … Some E/M codes are not typically reported with the Prolonged Services (codes +99354-+99357), either because no time is associated with the base E/M service and/or the services included in the E/M service already reflect an extensive duration of time and work.”

Ensure Providers Document ED E/M Services Correctly

For providers that don’t use ED E/Ms a lot, getting a handle on reporting (and documenting) 99281-99285 can be a task — but it’s one coders must take on for the good of the practice, says Falbo. “Educating clinicians on clinically significant and relevant documentation is key to achieving compliant coding and optimizing reimbursement. This is especially challenging in the ED because the provider documentation must support the ED provider’s professional services, as well as billing and coding for the facility.”

Hauptman says the documentation is also vital for ED patients’ records, as every visit — for every patient — is different. “It is important to review the documentation carefully to see when decisions were made and what comorbid conditions are being considered around this current emergent issue,” she says. “Also, the emergent nature of the problem could have been decided by the layperson — the patient — who decided to arrive at the emergency room for the condition. The care and steps for caring for the patient may be more involved than the ultimate diagnosis.”