Medicare Compliance & Reimbursement - 2018 Issue 4
E/M Coding: Here's How to Determine When 99285 is Warranted
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Article Overview
This premium article reviews emergency department E/M documentation standards and compares a high-level ED visit with related coding scenarios. It is aimed at coders, auditors, emergency department staff, and compliance readers who need to understand how documentation elements, medical decision-making, acuity considerations, and critical care services affect code selection. The discussion includes general guidance drawn from CPT®-based ED coding, references to payer review activity, and a critical care example involving separate procedure reporting and modifier use.
Why This Topic Matters
Emergency departments are often scrutinized for high-level E/M utilization, so accurate documentation and code selection can affect compliance, audit risk, and reimbursement. Understanding the distinctions discussed in the article helps readers evaluate whether the record supports the selected level of service and whether a different service category is more appropriate.
Article Sections
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Background
Introduces the coding question and notes payer review activity that prompted the discussion. Frames the article as guidance for emergency department billing and documentation review.
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Know the Elements
Reviews the documentation components associated with a high-level emergency department evaluation and management service. Focuses on the overall history, examination, and medical decision-making requirements.
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MDM Is Not Enough
Explains the relationship between medical decision-making and the other required documentation elements for emergency department E/M coding. Includes a brief scenario showing why documentation completeness affects level selection and mentions an acuity-related exception.
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Know When Critical Care Usurps 99285
Discusses situations where the service may align with critical care rather than a high-level ED visit. Includes a trauma-related example and references separate reporting of an associated procedure and modifier use.
What You Will Learn
- How emergency department E/M documentation is evaluated at a high level
- Which broad documentation elements must support a selected ED visit level
- How medical decision-making relates to ED code selection
- How acuity-related documentation exceptions may affect record review
- When a service may fit critical care guidance instead of a standard ED visit
- How separate procedure reporting may relate to a critical care scenario
Who Should Read This
- Emergency department coders
- Medical coders and auditors
- Revenue cycle and compliance staff
- Emergency department physicians and documentation staff
- Billing personnel
Codes Discussed
Modifiers Discussed
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