Basics of ED CPT code 99281, 99282, 99283, 99284 and 99285
The emergency department is defined as an organized, hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. It must be available 24 hours per day. Any physician seeing a patient registered in the emergency department may use emergency department visit codes. It is not required that the physician be assigned to the emergency department.
No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
The following codes (CPT code 99281-99285) are used to report evaluation and management services provided in the emergency department. No distinction is made between new and established patients in the emergency department.
Time may not be used to select levels of E/M services for the ED because ED services typically involve multiple encounters with several patients at various levels of intensity over an extended period of time. As a result, only MDM is used to select the level of ED services. This is unchanged from past guidelines and distinguishes ED services from the other E/M codes.
Read also: When to use Hydration CPT codes 96360 & 96361
Code description of CPT code 99281, 99282, 99283, 99284 & 99285
Emergency department service codes describe E/M services provided to patients in the emergency department (ED). ED codes are typically reported per day and do not differentiate between new or established patients. Other procedures or services performed in conjunction with the emergency room encounter may be reported separately.
Under the emergency department services category, there are five levels represented by 99281-99285. For the lowest level of care, CPT code 99281, services can be performed by clinical staff and must be face-to-face. The presence of a physician or qualified clinician is not required, but services are performed under their supervision.
There are no time or MDM requirements for CPT code 99281. The remaining levels, 99282-99285, require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM). Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management.
Time is not listed as a component in the code descriptors for emergency department services as these types of services are provided based on the varying intensity of the patient’s condition and may involve emergency providers caring for several patients over an extended period involving multiple encounters, making it difficult for the clinician to accurately detail the amount of time spent face-to-face with the patient.
CPT code 99282 is reported for a visit that entails straightforward MDM; CPT code 99283 is reported for a visit requiring a low level of MDM; CPT code 99284 is reported for a moderate level of MDM; and CPT code 99285 is reported for a high level of MDM.
The ED is considered an outpatient area in the facility. If services other than ED services are performed in the ED, a code from the Office or Other Outpatient Services subsection (99202-99215) may be appropriate to report. For example, if a patient is seen in the ED for the convenience of a physician or other QHP, report the appropriate office or other outpatient services code(s) 99202-99215.
ED services codes are not reportable in this scenario because the patient being seen in the ED setting was for the convenience of the physician or other QHP and not necessitated by an emergent medical need. However, CPT guidelines permit physicians and other QHPs who are not ED staff to report codes 99281-99285 when called to the ED to see the patient in the ED because that was the setting for the level of care required and provided.
How to determine Medical Decision Making ?
Within the E/M section of CPT, a grid is used to measure or “score” the Medical Decision Making (MDM). A combination of components determines the MDM.
1. The number and complexity of problem(s) addressed during the encounter.
2. The amount and/or complexity of data to be reviewed and analyzed.
3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), and treatment (s).
The Level of Emergency Department MDM is based on 2 out of 3 elements being met.
No changes were made to the straightforward element
2 additions were made to the low element. You can see below in the highlighted section
Number and Complexity of Problems Addressed at the Encounter
- 1 stable, acute illness;
- 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
No changes were made to the moderate element.
2 additions were made to the high element. Below are the highlighted addition for this element.
- Decision regarding hospitalization or escalation of hospital-level care
- Parenteral controlled substances
