Guidelines for Emergency Department Evaluation and Management Codes

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Guidelines for Emergency Department Evaluation
and Management Codes
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Guidelines for Emergency Department Evaluation
and Management Codes

• Guidelines for Emergency Department Evaluation
  and Management Codes
• As per CMS definition, an emergency department is
  defined as an organized hospital-based facility
  for the provision of unscheduled episodic
  services to patients who present for immediate
  medical attention. The basic requirement for
  emergency department (ED) is, the facility must
  be available 24 hours a day. Emergency department
  (ED) Evaluation and Management (E/M) codes do not
  differentiate between new or established patients
  and they are typically reported per day. There
  are 5 levels of emergency department services
  represented by CPT codes range 99281 99285. The
  emergency department codes require all three key
  components (history, examination, and medical
  decision-making) to be met and documented for the
  level of service selected.
• For critical care services provided in the
  emergency department, see Critical Care
  guidelines and 99291, 99292. Critical care and
  emergency department services may both be
  reported on the same day when after completion of
  the emergency department service, the condition
  of the patient changes and critical care services
  are provided.
• For evaluation and management services provided
  to a patient in observation status, see 99221,
  99222, 99223 for the initial observation
  encounter and 99231, 99232, 99233, 99238, 99239
  for subsequent or discharge hospital inpatient or
  observation encounters.
• For hospital inpatient or observation care
  services (including admission and discharge
  services), see 99234, 99235, 99236.

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Guidelines for Emergency Department Evaluation
and Management Codes

• To report services when a patient is admitted to
  a hospital inpatient or observation status, or to
  a nursing facility in the course of an encounter
  in another setting, see Initial Hospital
  Inpatient or Observation Care or Initial Nursing
  Facility Care.
• For procedures or services identified by a CPT
  code that may be separately reported on the same
  date, use the appropriate CPT code. Use the
  appropriate modifier(s) to report separately
  identifiable evaluation and management services
  and the extent of services provided in a surgical
  package.
• If a patient is seen in the emergency department
  for the convenience of a physician or other
  qualified health care professional, use office or
  other outpatient services codes (99202-99215).
• Note that, the time is not a descriptive
  component for the emergency department levels of
  evaluation and management services 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.
• Also note that, in the emergency department, no
  distinction is made between new and established
  patients. Evaluation and management services in
  the emergency department category may be reported
  for any new or established patient who presents
  for treatment in the emergency department.
• Applicable CPT Codes
• CPT 99281 Emergency department visit for the
  evaluation and management of a patient that may
  not require the presence of a physician or other
  qualified healthcare professional

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Guidelines for Emergency Department Evaluation
and Management Codes
CPT 99282 Emergency department visit for the
evaluation and management of a patient, which
requires a medically appropriate history and/or
examination and straightforward medical decision
making CPT 99283 Emergency department visit for
the evaluation and management of a patient, which
requires a medically appropriate history and/or
examination and a low level of medical decision
making CPT 99284 Emergency department visit for
the evaluation and management of a patient, which
requires a medically appropriate history and/or
examination and a moderate level of medical
decision making CPT 99285 Emergency department
visit for the evaluation and management of a
patient, which requires a medically appropriate
history and/or examination and a high level of
medical decision making Other Emergency
Services In directed emergency care, advanced
life support, the physician or other qualified
health care professional is located in a hospital
emergency or critical care department and is in
two-way voice communication with ambulance or
rescue personnel outside the hospital. The
direction of the performance of necessary medical
procedures includes but is not limited to
telemetry of cardiac rhythm cardiac and/or
pulmonary resuscitation endotracheal or
esophageal obturator airway intubation
administration of intravenous fluids and/or
administration of intramuscular, intratracheal or
subcutaneous drugs and/or electrical conversion
of arrhythmia.
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Guidelines for Emergency Department Evaluation
and Management Codes
Note that, The level of service billed must be
based on the intervention(s) that are performed
in relation to the medical care required by the
presenting symptoms and resulting in a diagnosis
of the patient. Professional codes are based on
complexity and performed work, which includes the
cognitive effort. Facility codes reflect the
volume and intensity of resources used by the
facility to provide care. Medical records and
documentation may be requested from the provider
to support the level of care rendered. The
documentation must clearly identify, and support
emergency department E/M codes billed. If a
denial is appealed, the supporting documentation
must be included in the appeal request. Insurance
reimbursement will depend upon group or
Individual benefit provider participation
agreement routine claim editing logic, including
but not limited to incidental or mutually
exclusive logic, and medical necessity and
mandated or legislatively required
criteria. Legion Healthcare Solutions is a
leading medical billing company providing
complete billing and coding services. Our coding
team is well-versed in guidelines for emergency
department evaluation and management codes. We
can assist you in the accurate selection of E/M
codes and modifiers. Legion Healthcare Solutions
is having extensive experience working with
eClincialWorks (ECW), Lytech, Medisoft,
AdvancedMD, Kareo, Office Ally, and all major
medical billing software. To know more about
Emergency Department (ED) coding services,
contact us at 727-475-1834 or email us at
info_at_legionhealthcaresolutions.com
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