cpt code emergency department visit

• Find a Doctor

Coding and Billing Guidelines for Emergency Department

• Provider Service: 800-368-2312
• For Medicaid Expansion: 833-777-5779
• Caring Foundation
• Privacy & Legal
• Our Partners in Health:

Fargo (Headquarters) 4510 13th Ave. S. Fargo, N.D., 58121

Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and businesses in North Dakota. All rights reserved.

© 2024 Blue Cross Blue Shield of North Dakota

• Non-Discrimination Notice
• العَرَبِيَّة
• Diné Bizaad

Processing...

Please wait while your form is being submitted

• Become a Member
• Everyday Coding Q&A
• Can I get paid
• Coding Guides
• Quick Reference Sheets
• E/M Services
• How Physician Services Are Paid
• Prevention & Screening
• Care Management & Remote Monitoring
• Surgery, Modifiers & Global
• Diagnosis Coding
• New & Newsworthy
• Practice Management
• E/M Rules Archive

April 4, 2024

Emergency Department Visits

Emergency department (ED) services are E/M services provided to patients in the Emergency Department.

Explanation

These services may be billed by any specialty physician, not just Emergency Department physicians. The physician does not need to be assigned to the ED. However, these codes may only be used in a hospital-based facility that is available 24 hours/day for unscheduled care to patients who present for immediate medical attention.

99282, 99283, 99284, 99285 – Emergency Department Visits, and in some cases, the office (99202-99215) and outpatient/consult codes (99242-99245.)

Want unlimited access to CodingIntel's online library?

Including updates on CPT ® and CMS coding changes for 2024

Last revised December 12, 2023 - Betsy Nicoletti Tags: emergency department

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

All content on CodingIntel is copyright protected. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos.

• What is CodingIntel
• Terms of Use
• Privacy Policy

Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

Copyright © 2024, CodingIntel A division of Medical Practice Consulting, LLC Privacy Policy

2023 Documentation Guideline Changes for ED E/M Codes 99281-99285

On July 1, 2022, the American Medical Association (AMA) released a preview of the 2023 CPT Documentation Guidelines for Evaluation and Management (E/M) services. These changes reflect a once-in-a-generation restructuring of the guidelines for choosing a level of emergency department (ED) E/M visit impacting roughly 85 percent of the relative value units (RVUs) for typical members. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the emergency department E/M services will be based only on medical decision making.

You Might Also Like

• Documentation Pearls for Navigating Abscess Incision/Drainage Codes
• ICD-10 Diagnosis Codes to Use for Zika Virus Documentation
• Avoid Patient History Documentation Errors in Medical Coding

Explore This Issue

The American College of Emergency Physicians (ACEP) represents the specialty in the AMA current procedural technology (CPT) and AMA/Specialty Society RVS Update Committee (RUC) processes. In fact, they are your only voice in those arenas. The AMA convened a joint CPT/RUC work group to refine the guidelines based on accepted guiding principles. Although the full CPT code set for 2023 has not yet been released, the AMA recognized that specialties needed to have access to the documentation guidelines changes early to educate both their physicians on what to document and their coders on how to extract the elements needed to determine the appropriate level of care based on chart documentation. Additionally, any electronic medical record or documentation template changes will need to be in place prior to January 1, 2023, to maintain efficient cash flows and ensure appropriate code assignment.

ACEP was able to convince the Joint CPT/RUC Workgroup that time should not be a descriptive element for choosing ED levels of service 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. It would be nearly impossible to track accurate times spent on every patient under concurrent active management.

The prior requirements to document a complete history and physical examination will no longer be deciding factors in code selection in 2023, but instead the 2023 Guidelines simply require a medically appropriate history and physical exam. That leaves medical decision making as the sole factor for code selection going forward. These changes are illustrated by the 2023 ED E/M code descriptors, which will appear as follows:

The 2023 E/M definitions have been updated to reflect simply Medical Decision Making determining the level.

• 99281: ED visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
• 99282: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
• 99283: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical decision making.
• 99284: ED visit for the evaluation and management of a patient which requires a medically appropriate history and/or examination and moderate medical decision making.
• 99285: ED visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision making.

Pages: 1 2 3 | Single Page

Topics: 2023 guidelines Coding CPT guidelines Practice Management Reimbursement & Coding

Medicare’s Reimbursement Updates for 2024

Workplace Violence and Mental Health in Emergency Medicine

Maryland Implements Value-Based Alternative Payment Model

Current issue.

ACEP Now: Vol 43 – No 03 – March 2024

Download PDF

No Responses to “2023 Documentation Guideline Changes for ED E/M Codes 99281-99285”

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *

• Skip to main content
• Skip to primary sidebar
• Skip to footer

Efficient MD

Improving physician efficiency

Efficient MD / December 17, 2018

A Simplified Explanation of Emergency Department E/M Coding

The way medical charts are coded and billed is unnecessarily convoluted, and you have the Centers for Medicare & Medicaid (CMS) to thank for that.  They are the ones who created the coding system that is used to assign an Evaluation & Management (E/M) level to our charts. Each chart is billed using a Current Procedure Terminology (CPT) code based on E/M levels 1-5.

Billing and coding is an extraordinarily boring topic.  I’m actually impressed that you’ve read this far. But I think it’s worth taking a little time to understand the basics in order to chart as efficiently as possible.  A level 5 chart does not necessarily require that you write a novel to meet the coding criteria. It is also possible to write a very long, thorough chart and still only get credit for a level 3 or 4 chart.  Unless you know the elements of the chart that count towards that level of coding, you may end up doing a lot of unnecessary work.

Rather than review the criteria for every component of each of the 5 CPT codes, which would be time-consuming and painful for you to read, I thought it would be most beneficial to go through a sample level 5 (CPT code 99285) ED visit, pointing out the potential pitfalls where your chart could possibly be down-coded to a level 4.

There are only 3 components that determine the E/M level:

1. HISTORY

2. PHYSICAL EXAM

3. MEDICAL DECISION MAKING

As I go through this sample case I will demonstrate the minimum amount of documentation needed for the chart to be coded as a level 5 chart.  I’m certainly not telling you to only document the minimum just to hit the level 5 criteria, as you should thoroughly chart  everything that is necessary for each patient. This is simply an exercise to illustrate the minimum documentation that would be needed solely for coding purposes.  Next to each of these 3 components, I will list in parentheses the minimum criteria required for that particular component. Keep in mind that the lowest scoring of the 3 components will determine the E/M level for the entire chart.

HISTORY ( HPI: Chief Complaint, 4+ elements, ROS: 10+ elements, PFSH: 2 of 3 elements)

The history component consists of 4 elements: chief complaint (CC), History of present illness (HPI), Review of systems (ROS), and Past medical, family and social history (PFSH).  A level 5 chart is designated “comprehensive” and includes 4+ HPI elements, 10+ ROS elements, and 2 of the 3 PFSH elements. What do you do if the patient is unable to provide a history because they are altered or intubated?  Or what if the patient refuses to give a history? Add a qualifier describing the reason for the limitation, such as “patient is unable to provide history secondary to…”. This will apply to all elements of the history component.

• CC – This is a mandatory element for all charts, regardless of CPT level.
• Modifying Factors
• Associated Signs/Symptoms

*In lieu of the HPI elements you could also document the status of 3 chronic or inactive conditions.

• Constitutional
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Hematologic/Lymphatic
• Allergic/Immunologic

A level 5 chart must document at least 10 organ systems.  Your EMR may have a button you can click that states something to the effect “all other systems reviewed and are negative.”  Clicking this button will technically satisfy the 10+ organ system ROS criteria, but doing so attests that you actually reviewed every organ system with the patient.  A word of caution: don’t document something that you didn’t do!

• Past Medical History (PMH) – Includes experiences with illnesses, operations, injuries, and treatments.
• Family History (FH) – Review of medical events, diseases, and hereditary conditions that may place the patient at risk.
• Social History (SH) – Includes sexual history, alcohol/drug use, employment, and education.

A level 5 chart must include at least one item each from 2 of the 3 components .  These are often documented by another staff member, such as the triage nurse.  If these are documented by another staff member they still counts toward your coding as long as you attest that their notes were “reviewed and verified by me.”

Let’s get to the sample case:

John Doe is a 60yo male with a history of hypertension and diabetes who presents to the emergency department complaining of chest pain .  He describes the pain as a “pressure” sensation in his left chest that began at 4pm today while walking .   He notes that his father died of an MI at age 65 .

This brief paragraph includes the chief complaint (chest pain), 4 HPI elements: quality (“pressure”), location (left chest), duration (began at 4pm), and context (while walking);  past medical history (history of hypertension and diabetes) and family history (father died of an MI at age 65). As long as you include your 10 ROS elements, you’ve met the minimum level 5 criteria for the HISTORY component of the chart!  If this were a real patient you would clearly want to include more details regarding his presentation, but again, I’m using this example just to illustrate that you don’t need to write a novel for your chart to be coded at a level 5.

Pitfall – Keep in mind that the PFSH consists of 3 distinct components: PMH, FH and SH.  You could list 10 medical conditions that the patient is suffering from but these all only count for 1 of these elements, the PMH.  If the entire chart meets criteria for a level 5 chart but only 1 of these 3 elements is documented, such as failing to document that the patient is a smoker or has a significant FH of heart disease, the HISTORY component of the chart will be downcoded to a level 4, which means the entire chart is downcoded to a level 4.

PHYSICAL EXAM ( 9 systems, with 2 bullets per system )

A level 5 chart requires a “comprehensive” physical exam, which consists of 9 systems, with 2 bullets per system.  CMS recognizes the following 14 systems as part of the physical exam:

• Ears, Nose, Mouth and Throat
• Chest (Breasts)

If you’d like to see the bullets that are within each of these systems, they can be found at the CMS website here .  I’ve found that the most efficient way to ensure that your chart meets level 5 coding criteria is to create a “normal” templated exam that includes the minimum 9 systems with 2 bullets per system and modifying it as needed.  However, if you choose to do this, be cautious! You need to know exactly what is in your templated exam and you must review it for each patient to ensure that you have not documented something that you did not actually do.  Again, don’t document something that you didn’t do .

MEDICAL DECISION MAKING   ( High )

The MDM section of your note is the most nebulous of the 3 components when it comes to understanding how it is coded.  There are 3 elements that are considered here, with the final code being based upon the highest 2 of the 3 following elements:

• The number of possible diagnoses and/or the number of management options that must be considered (I will refer to this as DIAGNOSES )
• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed (I will refer to this as DATA )
• The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options (I will refer to this as RISK )

DIAGNOSES – The highest score for this category is “extensive,” which is needed to bill as a level 5 chart.  If you are seeing a patient who is presenting with a problem that is new to you , the provider, and you are pursuing a workup of the presenting problem, this fulfills the “extensive” criteria.  If you are seeing the same patient, but not pursuing any workup, this component would be categorized as “multiple” rather than “extensive” and coded as a level 4 rather than a level 5.  As an emergency provider, nearly every patient you treat will be presenting with a problem that is new to you . A rare exception to this may be someone who is returning for a scheduled re-check.  

DATA – Again, the highest score for this category is “extensive,” which corresponds to a level 5 chart.  This section is calculated using a scoring system, with a score of 4 or greater needed to be considered “extensive.”  Here is the breakdown of the scoring :

• Review and/or order of clinical lab tests – ( 1 point )
• Review and/or order of radiology tests (excluding cardiac cath and echo) – ( 1 point )
• Review and/or order of medical tests (PFTs, colonoscopy, cath, echo) – ( 1 point )
• Discuss tests with performing physician (e.g., You discussed a colonoscopy result with the gastroenterologist.  You must document this discussion in your note.) – ( 1 point )
• Independent review of image, tracing, specimen* – ( 2 points )
• Reviewed and summarized old records or history from a person other than the patient (e.g., If you spoke with a consultant, even informally, this counts!  Just be sure to document the conversation in your note.) – ( 2 points )

* If documenting an ECG, your interpretation must include at least 3 of the 6 elements: rate/rhythm, axis, intervals, ST-segment changes, comparison to prior, summary of the patient’s clinical condition

RISK – Level of risk is scored from “minimal” to “high,” with a score of “high” needed to bill as a level 5 chart.  The risk score is calculated using a risk table, which is unwieldy and probably not worth your time to study. For our purposes, to understand what qualifies as a level 5 chart in the ED, suffice it to say that a patient who is sick and requires urgent intervention typically qualifies as a “high” level of risk.  Conditions that fall under this category include acute MI, pulmonary embolism, severe COPD exacerbation, multiple trauma, seizure, CVA, and psychiatric patients who are a threat to themselves or others.  Also note that any patient who receives a parenteral-controlled substance qualifies as “high” risk .  

Let’s revisit our patient who is presenting to the ED with chest pain.  His chief complaint is a problem that is new to us .  If we decide to pursue a workup for his chest pain (e.g., labs, ekg, cxr, etc.), the DIAGNOSES component of the MDM would meet the “extensive” criteria.  Now, in order for the MEDICAL DECISION MAKING element of the chart to qualify for level 5 billing, we just need either the DATA or RISK component to also meet the threshold for a level 5 chart.  Remember, you need 2 of the 3 components of the MDM ( DIAGNOSES, DATA and RISK ) to satisfy the highest level of billing in order for the MDM element to be billed as a level 5 chart.

Remember, the DATA component of the MDM is calculated based on points derived from various elements of the workup.  We need at least 4 points to satisfy the “extensive” level of billing required for a level 5 chart.  For this patient, if we order labs ( 1 point ), a chest x-ray ( 1 point ), and then document our interpretation of the chest x-ray ( 2 points ) we have a total of 4 points, which is sufficient to reach the “extensive” level of billing for the DATA component.

At this point the MDM element of the chart satisfies the billing criteria for a level 5 E/M code because 2 of the 3 elements of the MDM , the DIAGNOSES and DATA components, meet the maximum level of billing.  The RISK component of the MDM does not even need to be considered because the MDM can be billed as a level 5 chart without it.  However, if you had treated your patient’s chest pain with morphine during the encounter, this would have automatically bumped the RISK component to the maximum level, “high.”  If this were the case, all 3 of the MDM elements would satisfy the criteria for a level 5 chart, though only 2 of these 3 are needed.

To recap, a level 5 E/M chart requires that all 3 components of the chart, the HISTORY, PHYSICAL EXAM, and MDM, meet their respective maximum coding criteria.  Here are the 3 components with their respective level 5 billing criteria and the items from the chart that fulfill them:

CRITICAL CARE TIME

Critical care documentation is a special snowflake that warrants its own section.  CMS defines critical care as a medical condition that “impairs one or more vital organ systems” and is one in which “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”  They further note that the physician should provide “frequent personal assessment and manipulation” of the patient’s condition.

Here is a list of diagnoses that suggest critical care billing may be appropriate:

• Active seizures
• Acute altered mental status
• Acute GI bleed
• Acute psychosis with agitation
• Acute stroke
• Cardiac arrest
• Delirium tremens
• Ectopic pregnancy
• Hyperkalemia requiring treatment
• Hypovolemic shock
• Intracerebral hemorrhage
• Moderate to severe asthma
• Moderate to severe CHF
• Overdose requiring antidotes or reversal agents
• Pneumothorax
• Pulmonary embolus
• Rapid atrial fibrillation
• Respiratory distress requiring non-invasive positive pressure ventilation
• Respiratory distress requiring intubation
• Severe anemia requiring blood transfusion
• Suicidal ideation immediate threat
• Unstable angina

In addition to the patient having a critical condition, in order to bill for critical care time, you need to have spent 30 minutes or more on patient care .  This includes time spent on direct patient care, as well as time spent on indirect patient care.  Indirect patient care may include documentation, reviewing prior records, and speaking with consultants, paramedics, and family members.  It is important to note that critical care time does not include time spent on procedures that are billed separately, such as intubations and central lines.

Some critically-ill patients may not qualify for critical care billing .  If a patient with a STEMI is brought in by ambulance and then whisked off to the cath lab within 10 minutes of arrival, they would typically not qualify for critical care billing, regardless of how unstable they were.  At least 30 minutes of time must be spent on patient care to bill for critical care.

If you care for a patient who meets the criteria for critical care billing and document it as such, these CPT codes ( 99291 for the first 30-74 minutes, 99292 for each additional 30 minutes beyond the first 74 minutes) supercede all of the elements discussed above for coding a E/M level 5 chart.  Meaning, if you didn’t document a social history and your ROS only includes 8 organ systems instead of the 10 required for a level 5 chart, it will still be billed as a critical care chart.

Keep in mind that some patients may appear clinically stable but still qualify for critical care billing.  The hyperkalemic patient who requires treatment, monitoring and frequent reassessments may qualify. As may the asthmatic who requires BiPAP and frequent reassessments.  

Congrats on making it to the end!  I hope this has been helpful. If you have any feedback for me regarding this article please contact me at [email protected] .

Disclaimer: This article was written for informational purposes only.  I cannot guarantee the accuracy of the information provided. Payment policies can vary from payer to payer.  I assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of, or relating to, the use, non-use, interpretation of, or reliance on information contained here.  Specific coding or payment related issues should be directed to the payer.

Share this:

• Click to print (Opens in new window)
• Click to share on Facebook (Opens in new window)
• Click to share on Twitter (Opens in new window)
• Click to share on LinkedIn (Opens in new window)
• Click to share on Reddit (Opens in new window)

[email protected]

Disclaimer » Advertising

• HealthyChildren.org
• Facebook Icon
• Twitter Icon
• LinkedIn Icon

Emergency department E/M codes revised for 2023

Revisions to the Current Procedural Terminology (CPT) codes for Office or Other Outpatient evaluation and management (E/M) (99202-99215) took effect in 2021. The remainder of the E/M sections in the CPT code set will be revised for 2023.

Toward that end, the CPT Editorial Panel revised the five emergency department (ED) E/M codes (99281-99285) to align with the principles included in the Office or Other Outpatient services.

The E/M revisions are intended to simplify coding and documentation requirements for health care providers and improve patient health under the following principles:

• to decrease administrative burden of documentation and coding and align CPT and Centers for Medicare & Medicaid Services (CMS) guidelines whenever possible;
• to decrease the need for audits;
• to decrease documentation in the medical record that is not needed for patient care; and
• to ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties.

Following are the key revisions to the ED E/M codes that will become effective with the CPT 2023 code set:

• E/M services in the ED that were selected based on key components (history, examination and medical-decision-making [MDM]) will be selected based on MDM alone for services provided in 2023.
• No distinction will be made between new and established patients in the ED; E/M services in the ED category may be reported for any new or established patient who presents for treatment in the ED.
• Time will not be a descriptive component for the ED levels of E/M services because ED services typically are provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
• The highest two of three elements of MDM will be used to select the level of an ED E/M code:
• Problem(s): the number and complexity of presenting problems;
• Data: the amount and/or complexity of data to be reviewed and analyzed; and
• Risk: The risk of complications and/or morbidity or mortality of patient management.
• The concept of the level of MDM will not apply to code 99281 because this level of service will not require the presence of a physician/other qualified health care professional (QHP).
• All levels of ED service will include a medically appropriate history and examination as determined by the treating physician/QHP.
• As medical necessity will be an overarching criterion for selecting the level of ED E/M service, the physician/QHP will have to consider whether the nature of the presenting problem supports the medical necessity of services rendered.

New ICD-10-CM codes for COVID immunization status

On April 1, the National Center for Health Statistics released several new International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) codes:

• New code: Z28.310 Unvaccinated for COVID-19
• New code: Z28.311 Partially vaccinated for COVID-19
• ➢Delinquent immunization status
• ➢Lapsed immunization schedule status

Copyright © 2022 American Academy of Pediatrics

Advertising Disclaimer »

Email alerts

1. Tips to help prevent overuse injuries in young athletes

2. Pediatrics fill rate dips during 2024 Match

3. Alpha thalassemia trait often confused for iron deficiency anemia

April issue digital edition

Subscribe to AAP News

Column collections

Topic collections

Affiliations

Advertising.

• Submit a story
• American Academy of Pediatrics
• Online ISSN 1556-3332
• Print ISSN 1073-0397
• Pediatrics Open Science
• Hospital Pediatrics
• Pediatrics in Review
• AAP Grand Rounds
• Latest News
• Pediatric Care Online
• Red Book Online
• Pediatric Patient Education
• AAP Toolkits
• AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations.

• Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
• © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account