cpt code emergency room visit level 4

Emergency CPT – 99283, 99284, 99285, 99281, 99282

by Medical Billing | Jan 9, 2013 | CPT modifiers | 1 comment

99283 (CPT G0382) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.

99284 (CPT G0383) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. average fee payment – $110 – $120 Moderate-High Complexity (99284/G0383): The presented problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration.

99285 (G0384) 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. average fee amount – $170 – $180

99288 Physician direction of emergency medical systems (EMS) emergency care, advanced life support Billing and Coding Guidelines. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 93005 (Twelve lead ECG) Example #2: A patient is seen in the ED after a fall. Lacerations sustained from the fall are repaired and radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 12001-13160 (Repair/Closure of the Laceration) 70010-79900 (Radiological X-ray) Example #3: A patient is seen in the ED after a fall, complaining of shoulder pain. Radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 70010-79900 (Radiological X-ray) NOTE: Using example #3 above, if a subsequent ED visit is made on the same date, but no further procedures are performed, appending modifier –25 to that subsequent ED E/M code is NOT appropriate. However, in this instance, since there are two ED E/M visits to the same revenue center (45X), condition code G0 (zero) must be reported in form locator 24 or the corresponding electronic version of the UB92. Per CPT definition, the codes 99281-99285 are for reporting evaluation and management services in the emergency department. 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 facility must be available 24 hours a day. Based on this definition, codes 99281-99285 will be denied provider liable as incompatible if submitted with any place of service (POS) other than 23.

If my patient is registered in the emergency department and I am asked to see him/her, may I submit the emergency service? Answer: Yes. Any physician seeing a patient registered in the emergency department (ED) may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the ED. If the patient is admitted by this provider, the initial hospital service (CPT codes 99221-99223) with the AI HCPCS modifier would be submitted instead of the ED visit codes. Please keep in mind the service must be medically necessary and the documentation must meet the level of complexity of the service rendered. The following guidelines apply to the ED CPT codes 99281 through 99285 billing: ED service is provided to the patient by both the patient’s personal physician and ED physician. If the ED physician, based on the advice of the patient’s personal physician who came to the ED to see the patient, sends the patient home, then the ED physician should bill the appropriate level of ED service. The patient’s personal physician should also bill the level of ED code that describes the service he or she provided in the ED. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient’s personal physician may not bill. If the ED physician requests that another physician evaluate a given patient, the other physician should bill an ED visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he/she should bill an initial hospital care code and not an ED visit code. Overuse and Misuse of CPT Code 99285 The Arizona Healthcare Cost Containment System’s (AHCCCS) Claims Medical Review Unit has noted an increased use of CPT code 99285 on claims for billed emergency room visits. When submitting a claim using CPT code 99285, please document the following: • Comprehensive history • Comprehensive examination • Medical decision for services involving high complexity conditions. Usually the presenting problem(s) are of high severity, are a potential life threatening problem and require the immediate attention of the physician. Services for constipation, earaches and colds, for example, should not be billed using CPT code 99285. AHCCCS will refer any improper billing trends to the Office of the Inspector General.

CPT Code 99285 Emergency Department Visit: 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: • Comprehensive history • Comprehensive examination • Medical decision making of HIGH complexity Comprehensive History: • Reason for admission • Problem pertinent review of systems • Extended history of present illness (HPI) – Includes 4 or more elements of the HPI or the status of at least three chronic or inactive conditions • Review of systems directly related to the problem(s) identified in the HPI • Medically necessary review of ALL body systems’ history • Medically necessary complete past, family, and social history HPI – History of Present Illness: A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include: • Location • Quality • Severity • Timing • Context • Modifying factors • Associated signs/symptoms significantly related to the presenting problem(s) Chief Complaint: The Chief Complaint is a concise statement from the patient describing: • The symptom • Problem • Condition • Diagnosis • Physician recommended return, or other factor that is the reason for the encounter Review of Systems: An inventory of body systems obtained through a series if questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purpose of Review of Systems the following systems are recognized: • Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic Past, Family, and/or Social History (PFSH): Consists of a review of the following: • Past history (patient’s past experiences with illnesses, operations, injuries, and treatments • Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk) • Social History (an age appropriate review of past and current activities Additional Information: • Medicare Providers are responsible for assuring that visits are coded accurately; the unique provider number used when a service is billed ensures that the provider has reviewed and authenticated the accuracy of everything on the submitted claim. • Clearly document your clinical perception of the patient’s condition to assure claims are submitted with the correct level of service. • Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making. • Practitioner’s choosing to use time as the determining factor: – MUST document time in the patient’s medical record – Documentation MUST support in sufficient detail the nature of the counseling – Code selection based on total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection Coding Guidelines Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.” Exceptions to Modifier 59 Override: The Health Plan has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending modifier 59 to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement (See also our Screening Services with Evaluation & Management Services and our Bundled Services and Supplies reimbursement policies.): • Duplicate coding • Services and supplies specified in the Bundled Services and Supplies Policy • E/M or DME item codes • National Correct Coding Initiative (NCCI) edit code pairs with a ‘superscript’ of zero, or a modifier allowance indicator of zero. • In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples: 700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (These code ranges include all applicable radiology interpretation codes, as well as radiology codes with modifier 26) reported with 99221-99233 and 99281-99285* 93010, 93018, 93042, 93303, 93307-93308, 93312-93318, 93320-93321, 93325, 93350-93352, and 0180T reported with 99281-99285 Modifier 25 Guidelines 1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25. 2. Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are: 99201-99215 (Office or Outpatient Services) 99281-99285 (Emergency Department Services) 99291 (Critical Care Services) 99241-99245 (Office or Other Outpatient Consultations) NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to “physician” are to be disregarded. Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon. The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier –25 appended should be reported to indicate that the afternoon hypertension clinic visit was not related to the pulmonary function testing. 3. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported: 99281-99285 (Emergency Department Services) with a modifier –25 93005 (Twelve lead ECG) 045X 99281-99285, 99291 Emergency visit hospital billing UB 04 *Revenue codes have not been identified for these procedures, as they can be performedin a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360), or clinic (0510). Hospitals are to report these HCPCS codes under the revenue center where they were performed. EXAMPLE 1 If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, two separate bills may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to OPPS. In this situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit. EXAMPLE 2 If a patient was seen in the emergency room (ER) and the same patient received nonpartial hospitalization psychological services on the same day as well as several other days in the month, the provider should report the ER visit on the monthly repetitive claim along with the psychological services, since both services are paid under OPPS. Days after the date covered services ended, such as noncovered level of care, or emergency services after the emergency has ended in nonparticipating institutions; • Days for which no Part A payment can be made because the patient was on a leave of absence and was not in the hospital. • Days for which no Part A payment can be made because a hospital whose provider agreement has terminated, expired, or been cancelled may be paid only for covered inpatient services during the limited period following such termination, expiration, or cancellation. All days after the expiration of the period are noncovered. See Chapter 3 for determining the effective date of the limited period and for billing for Part B services; and • Days after the time limit when utilization is not chargeable because the beneficiary is at fault. FL 19 – Type of Admission/Visit Required on inpatient bills only. This is the code indicating priority of this admission. Code Structure: 1 Emergency – The patient required immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient was admitted through the emergency room. 2 Urgent- The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available, suitable accommodation. 3 Elective – The patient’s condition permitted adequate time to schedule the availability of a suitable accommodation. FL 20 – Source of Admission Required For Inpatient Hospital. The provider enters the code indicating the source of this admission or outpatient registration. Code Structure (For Emergency, Elective, or Other Type of Admission): 1 Physician Referral Inpatient: The patient was admitted to this facility upon the recommendation of their personal physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by their personal physician or the patient independently requested outpatient services (self-referral). 2 Clinic Referral Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s clinic physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by this facility’s clinic or other outpatient department physician. 3 HMO Referral Inpatient: The patient was admitted to this facility upon the recommendation of a HMO physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a HMO physician. 4 Transfer from a Hospital Inpatient: The patient was admitted to this facility as a transfer from an acute care facility where they were an inpatient Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another acute care facility. 5 Transfer from a SNF Inpatient: The patient was admitted to this facility as a transfer from a SNF where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where they are an inpatient. 6 Transfer from Another Health Care Facility Inpatient: The patient was admitted to this facility from a health care facility other than an acute care facility or SNF. This includes transfers from nursing homes, long term care facilities and SNF patients that are at a nonskilled level of care. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where they are an inpatient. 7 Emergency Room Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s emergency room physician. Outpatient: The patient received services in this facility’s emergency department. 8 Court/Law Enforcement Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. Outpatient: The patient was referred to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services. 9 Information Not Available Inpatient: The means by which the patient was admitted to this facility is not known. Outpatient: For Medicare outpatient bills, this is not a valid code. A Transfer from a Critical Access Hospital (CAH) Inpatient: The patient was admitted to this facility as a transfer from a CAH where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient. Code Title Definition 44 Inpatient Admission Changed to Outpatient For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. Effective April 1, 2004 45 Reserved for national assignment 46 Non-Availability Statement on File A nonavailability statement must be issued for each TRICARE claim for nonemergency inpatient care when the TRICARE beneficiary resides within the catchment area (usually a 40-mile radius) of a Uniformed Services Hospital. 47 Reserved for TRICARE Code Title Definition 59 Non-primary ESRD Facility Code indicates that ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility. 60 Operating Cost Day Outlier Day Outlier obsolete after FY 1997. (Not reported by providers, not used for a capital day outlier.) PRICER indicates this bill is a length-of-stay outlier. The FI indicates the cost outlier portion paid value code 17. AM Non-emergency Medically Necessary Stretcher Transport Required For ambulance claims. Non-emergency medically necessary stretcher transport required. Effective 10/16/03 AN Preadmission Screening Not Required Person meets the criteria for an exemption from preadmission screening. Effective 1/1/04 G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0. Code Title Definition A4 Covered Self-Administrable Drugs – Emergency The amount included in covered charges for self-administrable drugs administered to the patient in an emergency situation. (The only covered Medicare charges for an ordinarily noncovered, selfadministered drug are for insulin administered to a patient in a diabetic coma. 045X Emergency Room Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care. Rationale: Permits identification of particular items for payers. Under the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital with an emergency department must provide, upon request and within the capabilities of the hospital, an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual’s eligibility for Medicare (Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985). Subcategory Standard Abbreviations 0 – General Classification EMERG ROOM 1 – EMTALA Emergency Medical screening services ER/EMTALA 2 – ER Beyond EMTALA Screening ER/BEYOND EMTALA 6 – Urgent Care URGENT CARE 9 – Other Emergency Room OTHER EMER ROOM 051X Clinic Clinic (nonemergency/scheduled outpatient visit) charges for providing diagnostic, preventive, curative, rehabilitative, and education services to ambulatory patients.Rationale: Provides a breakdown of some clinics that hospitals or third party payers may require. Subcategory Standard Abbreviations 0 – General Classification CLINIC 1 – Chronic Pain Center CHRONIC PAIN CL 2 – Dental Clinic DENTAL CLINIC 3 – Psychiatric Clinic PSYCH CLINIC Usage Notes: 1. To be used by trauma center/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. 2. Revenue Category 068X is used for patients for whom a trauma activation occurred. A trauma team activation/response is a “Notification of key hospital personnel in response to triage information from pre-hospital caregivers in advance of the patient’s arrival.” 3. Revenue Category 068X is for reporting trauma activation costs only. It is an activation fee and not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will normally be both a 045X and 068X revenue code reported. 4. Revenue Category 068X is not limited to admitted patients. 5. Revenue Category 068X must be used in conjunction with FL 19 Type of Admission/Visit code 05 (“Trauma Center”), however FL 19 Code 05 can be used alone. 098X Professional Fees – Extension of 096X & 097X Subcategory Standard Abbreviations 1 – Emergency Room PRO FEE/ER 2 – Outpatient Services PRO FEE/OUTPT 3 – Clinic PRO FEE/CLINIC 4 – Medical Social Services PRO FEE/SOC SVC 5 – EKG PRO FEE/EKG 6 – EEG PRO FEE/EEG 7 – Hospital Visit PRO FEE/HOS VIS 8 – Consultation PRO FEE/CONSULT 9 – Private Duty Nurse FEE/PVT NURSE • Accommodations – 0100s – 0150s, 0200s, 0210s (days) • Blood pints – 0380s (pints) • DME – 0290s (rental months) • Emergency room – 0450, 0452, and 0459 (HCPCS code definition for visit or procedure) • Clinic – 0510s and 0520s (HCPCS code definition for visit or procedure) • Dialysis treatments – 0800s (sessions or days) • Orthotic/prosthetic devices – 0274 (items) • Outpatient therapy visits – 0410, 0420, 0430, 0440, 0480, 0900, and 0943 (Units are equal to the number of times the procedure/service being reported was performed.) • Outpatient clinical diagnostic laboratory tests – 030X-031X (tests) • Radiology – 032x, 034x, 035x, 040x, 061x, and 0333 (HCPCS code definition of tests or services) • Oxygen – 0600s (rental months, feet, or pounds) • Drugs and Biologicals- 0636 (including hemophilia clotting factors) If the patient is self-referred (e.g., emergency room or clinic visit), the provider enters SLF000 in the first six positions, and does not enter a name FL19 – Type of Admission a. One numeric position. b. Required only if the type of bill is 11X or 41X. c. Valid codes are: 1 Emergency 2 Urgent 3 Elective 9 Information unavailable c. Valid codes are: 1. Physician referral 2. Clinic referral 3. HMO referral 4. Transfer from a hospital 5. Transfer from a SNF 6. Transfer from another health care facility 7. Emergency room 8. Court/Law enforcement 9. Information not available A. Inpatient – Patient admitted to this facility as an inpatient transfer from a CAH. Outpatient – Patient referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH where the patient is an inpatient. B. Patient admitted to this HHA as a transfer from another HHA. C. Patient readmitted to this HHA within the same home health episode period.

Reimbursement for emergency inpatient hospital services is permitted only for those periods during which the patient’s state of injury or disease is such that a health or life-endangering emergency existed and continued to exist, requiring immediate care that could be provided only in a hospital. The allegation that an emergency existed must be substantiated by sufficient medical information from the physician or hospital. If the physician’s statement does not provide it, or is not supplemented by adequate clinical corroboration of this allegation, it does not constitute sufficient evidence. Death of the patient does not necessarily establish the existence of a medical emergency, since in some chronic, terminal illnesses, time is available to plan admission to a participating hospital. The lack of adequate care at home or lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission, without an immediate threat to the life and health of the patient. Since the existence of medical necessity for emergency services is based upon the physician’s assessment of the patient prior to admission, serious medical conditions developing after a non-emergency admission are not “emergencies” under the emergency services provisions of the Act. The emergency ceases when it becomes safe, from a medical standpoint, to move the individual to a participating hospital, another institution, or to discharge the individual. Emergency Medical Condition Federal Medicaid regulations define an emergency medical condition (including emergency labor and delivery) as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to: ** Place the person’s health in serious jeopardy; or ** Cause serious impairment to bodily functions; or ** Cause serious dysfunction of any bodily organ or part.

B. Criteria Since the decision that a medical emergency existed can be a matter of subjective medical judgment involving the entire gamut of disease and accident situations, it is impossible to provide arbitrary guidelines. 1. Diagnosis is Considered “Usually an Emergency” An emergency condition is an unanticipated deterioration of a beneficiary’s health which requires the immediate provision of inpatient hospital services because the patient’s chances of survival, or regaining prior health status, depends upon the speed with which medical or surgical procedures are, or can be, applied. While many diagnoses (e.g., myocardial infarction, acute appendicitis) are normally considered emergencies, the hospital must check medical documentation for internal consistencies (e.g., signs and symptoms upon admission, notations concerning changes in a preexisting condition, results of diagnostic tests). EXAMPLE: If the diagnosis is given as “coronary,” the physician’s statement is “coronary,” without further explanatory remarks, and the statement of services rendered gives no indication that an electrocardiogram was taken, or that the patient required intensive care, etc., further information is required. On the other hand, if the diagnosis is one that ordinarily indicates a medical and/or surgical emergency, and the treatment, diagnostic procedures, and period of hospitalization are consistent with the diagnosis, further documentation may be unnecessary. An example is: admitting diagnosis – appendicitis; discharge diagnosis – appendicitis; surgical procedures – appendectomy; period of inpatient stay – 7 days. 2. Patient Dies During Hospitalization If an emergency existed at the time of admission and the patient subsequently expires, the claim is allowed for emergency services if the period of coverage is reasonable. However, death of the patient is not prima facie evidence that an emergency existed; e.g., death can occur as a result of elective surgery or in the case of a chronically ill patient who has a long terminal hospitalization. Such claims are denied. 3. Patient’s Physician Does Not Have Staff Privileges at a Participating Hospital The fact that the beneficiary’s attending physician does not have staff privileges at a participating hospital has no bearing on the emergency services determination. If the lack of staff privileges in an accessible participating hospital is the governing factor in the decision to admit the beneficiary to an “emergency hospital,” the claim is denied irrespective of the seriousness of the medical situation. 4. Beneficiary Chooses to be Admitted to a Nonparticipating Hospital The claim is denied if the beneficiary chooses to be admitted to a non-participating hospital as a personal preference (e.g., participating hospital is on the other side of town) when a bed for the required service is available in an accessible, participating hospital. 5. Beneficiary Cannot be Cared for Adequately at Home The patient who cannot be cared for adequately at home does not necessarily require emergency services. The claim is denied in the absence of an injury, the appearance of a disease or disorder, or an acute change in a pre-existing disease state which poses an immediate threat to the life or health of the individual and which necessitates the use of the most accessible hospital equipped to furnish emergency services. 6. Lack of Suitable Transportation to a Participating Hospital Lack of transportation to a participating hospital does not, in and of itself, constitute a reason for emergency services. The availability of suitable transportation can be considered only when the beneficiary’s medical condition contraindicates taking the time to arrange transportation to a participating hospital. The claim is denied if there is no immediate threat to the life or health of the individual, and time could have been taken to arrange transportation to a participating hospital. 7. “Emergency Condition” Develops Subsequent to a Non-emergency Admission to a Nonparticipating Hospital Program payment cannot be made for emergency services furnished by a nonparticipating hospital when the emergency condition arises after a non-emergency admission. An example: treatment of postoperative complications following an elective surgical procedure or treatment of a myocardial infarction that occurred during a hospitalization for an elective surgical procedure. The existence of medical necessity for emergency services is based upon the physician’s initial assessment of the apparent condition of the patient at the time of the patient’s arrival at the hospital, i.e., prior to admission. 8. Additional “Emergency Condition” Develops Subsequent to an Emergency Admission to a Nonparticipating Hospital If the patient enters a nonparticipating hospital under an emergency situation and subsequently has other injuries, diseases or disorders, or acute changes in preexisting disease conditions, related or unrelated to the condition for which the patient entered, which pose an immediate threat to life or health, emergency services coverage continues. Emergency services coverage ends when it becomes safe from a medical standpoint to move the patient to an available bed in a participating institution or to discharge the patient, whichever occurs first. Emergency Medical Condition An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If you didn’t get immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would have serious damage to any part or organ of your body. Emergency Medical Transportation Ambulance services for an emergency medical condition. Types of emergency medical transportation may include transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or may pay less for certain types. Emergency Room Care / Emergency Services Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions. Urgent Care Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. MISUTILIZATION OF EMERGENCY DEPARTMENT SERVICES Criteria include, but are not limited to, the following: ** More than three emergency department visits in one quarter. ** Repeated emergency department visits with no follow-up with a primary care provider (PCP) or specialist when appropriate. ** More than one outpatient hospital emergency department facility in one quarter. ** Repeated emergency department visits for non-emergent conditions. Emergency Department Visits (Codes 99281 – 99288) A.Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department. B.Use of Emergency Department Codes In Office Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. 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. C.Use of Emergency Department Codes to Bill Nonemergency Services Services in the emergency department may not be emergencies. However the codes (99281 – 99288) are payable if the described services are provided. However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physician’s office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate office/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition. D.Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment for initial nursing facility care when performed on the same date as the nursing facility admission. E.Physician Billing for Emergency Department Services Provided to Patient by Both Patient’s Personal Physician and Emergency Department Physician If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether the patient should be admitted to the hospital or be sent home, the physicians should bill as follows: *If the patient is admitted to the hospital by the patient’s personal physician, then the patient’s regular physician should bill only the appropriate level of the initial hospital care (codes 99221 – 99223) because all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes. *If the ED physician, based on the advice of the patient’s personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient’s personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient’s personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patient’s personal physician may not bill. F.Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

Reimbursement Information:BCBS guidelines

The patient’s medical record documentation for diagnosis and treatment in the Emergency Department (ED) must indicate the presenting symptoms, diagnoses and treatment plan and a written order by the physician should be clearly documented in the medical record. Medical records and itemized bills may be requested from the provider to support the level of care that is rendered. Medical records will be used to determine the extent of history, extent of examination performed, complexity of medical decision making (number of diagnoses or management options, amount and/or complexity of data to be reviewed and risk of complications and/or morbidity or mortality) and services rendered. This information will be reviewed in conjunction with the level of care billed and evaluated for appropriateness.

Applicable service codes: Revenue code 450 and/or one of the following procedure codes 99281, 99282, 99283, 99284, 99285, 99288, 99291, 99292, G0380, G0381, G0382, G0383, and G0384.

If observation services are billed with any of the ER associated Evaluation and Management codes, MCG Criteria will be used to evaluate the medical necessity of these observation hours.

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the Clinical Payment and Coding Policy criteria listed below. The ED provides services to patients who are there for immediate medical attention. The physician or other qualified healthcare professional level of service is determined by the following:

1. Straight Forward Complexity (99281/G0380):

The presented problem(s) are self-limited or minor conditions with no medications or home treatment required.

Emergency department visit for the evaluation and management of a patient, which requires these

3 key components:

1) A problem focused history; 2) A problem focused examination; and 3) Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor.

2. Low Complexity (99282/G0381):

The presented problem(s) are of low to moderate severity. Over the counter (OTC) medications or treatment, simple dressing changes; patient demonstrates understanding quickly and easily. Emergency department visit for the evaluation and management of a patient, which requires these

1) An expanded problem focused history; 2) An expanded problem focused examination; and 3) Medical decision making of low complexity.

3. Moderate Complexity (99283/G0382):

The presented problem(s) are of moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

1) An expanded problem focused history; 2) An expanded problem focused examination; and 3) Medical decision making of moderate complexity.

4. Moderate-High Complexity (99284/G0383): Usually, the presented problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

1) A detailed history; 2) A detailed examination; and 3) Medical decision making of moderate complexity.

5. High Complexity (99285/G0384):

The presented problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 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:

1) A comprehensive history; 2) A comprehensive examination; and 3) Medical decision making of high complexity.

6. Physician direction of Emergency Medical Systems (EMS) emergency care, advanced life support. (99288)

7. Critical Care (99291) & 99292

The assignment of the Critical Care code 99291 likewise follows the same instructions applicable to the six E&M codes listed above. There is a 30 minute time requirement for facility billing of critical care. The first 30-74 minutes equal code 99291. Any additional 30 minute increments beyond the first 74 minutes is coded 99292.

IV CPT 99284

Type A: APC 615 Type B: APC 629 HCPCS: G0383

Could include interventions from previous levels, plus any of: Preparation for 2 diagnostic tests: (Labs, EKG, X-ray) Prep for plain X-ray (multiple body areas):

C-spine & foot, shoulder & pelvis Prep for special imaging study (CT, MRI, Ultrasound,VQ scans) Cardiac Monitoring (2) Nebulizer treatments

Port-a-cath venous access

Administration and Monitoring of infusions or parenteral medications (IV, IM, IO, SC) NG/PEG Tube Placement/Replacement Multiple reassessments Prep or assist w/procedures such as: eye irrigation with Morgan lens, bladder irrigation with 3-way foley, pelvic exam, etc.

Sexual Assault Exam w/ out specimen collection Psychotic patient; not suicidal

Discussion of Discharge Instructions (Complex) Blunt/ penetrating trauma- with limited diagnostic testing Headache with nausea/

vomiting Dehydration requiring treatment

Vomiting requiring treatment

Dyspnea requiring oxygen Respiratory illness relieved with (2) nebulizer treatments

Chest Pain–with limited diagnostic testing Abdominal Pain – with limited diagnostic testing

Non-menstrual vaginal bleeding Neurologic symptoms – with limited diagnostic testing V

Type A: APC 616 Could include interventions from previous levels, plus any of:

Requires frequent monitoring of multiple vital signs (i.e. 02 sat, BP, cardiac rhythm, respiratory rate) Preparation for = 3 diagnostic tests: (Labs, EKG, X-ray) Prep for special imaging study (CT, MRI, Ultrasound, VQ Blunt/ penetrating trauma requiring multiple diagnostic tests Systemic multi-system medical emergency requiring multiple Medicare payment guidelines

All of the following requirements must be met in order for a hospital to receive an APC payment for the extended assessment and management composite APCs:

1. Observation Time

a. Observation time must be documented in the medical record.

b. A beneficiary’s time in observation (and hospital billing) begins with the beneficiary’s admission to an observation bed.

c. A beneficiary’s time in observation (and hospital billing) ends when all clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be released or admitted as an inpatient.

d. The number of units reported with HCPCS code G0378 must equal or exceed 8 hours.

2. Additional Hospital Services

a. The claim for observation services must include one of the following services in addition to the reported observation services. The additional services listed below must have a line item date of service on the same day or the day before the date reported for observation:

• An emergency department visit (CPT code 99284 or 99285) or

• A clinic visit (CPT code 99205 or 99215); or

• Critical care (CPT code 99291); or

• Direct admission to observation reported with HCPCS code G0379, must be reported on the same date of service as the date reported for observation services.

b. No procedure with a “T” status indicator can be reported on the same day or day before observation care is provided.

3. Physician Evaluation

a. The beneficiary must be in the care of a physician during the period of observation, as documented in the medical record by admission, discharge, and other appropriate progress notes that are timed, written, and signed by the physician. b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.

4. Payment for Direct Admission to Observation

For CY 2008, direct admission to observation care continues to be reported using HCPCS code G0379 (Direct admission of patient for hospital observation care). Hospitals should report G0379 when observation services are the result of a direct admission to observation care without an associated emergency room visit, hospital outpatient clinic visit, critical care service, or surgical procedure (T status procedure) on the day of initiation of observation services. Hospitals should only report HCPCS code G0379 when a patient is admitted directly to observation care after being seen by a physician in the community.

Payment for direct admission to observation will be made either separately as a low level hospital clinic visit under APC 604, packaged into payment for composite APC 8002 (Level I Prolonged Assessment and Management Composite), or packaged into payment for other separately payable services provided in the same encounter.

The criteria for payment of HCPCS code G0379 under either APC 8002 or APC 0604 include:

1. Both HCPCS codes G0378 (Hospital observation services, per hr) and G0379 (Direct admission of patient for hospital observation care) are reported with the same date of service.

2. No service with a status indicator of T or V or Critical Care (APC 0617) is provided on the same date of service as HCPCS code G0379.

If either of the above criteria is not met, HCPCS code G0379 will be assigned status indicator N and will be packaged into payment for other separately payable services provided in the same encounter.

Composite APCs and Criteria for Composite Payment Composite APC

Composite APC Title Criteria for Composite Payment 8000 Cardiac Electrophysiologic

Evaluation and Ablation Composite

At least one unit of CPT code 93619 or 93620 and at least one unit of CPT code 93650, 93651 or 93652 on the same date of service 8001 Low Dose Rate Prostate

Brachytherapy Composite One or more units of CPT codes 55875 and 77778 on the same date of service 8002 Level I Extended Assessment and Management Composite

1) 8 or more units of HCPCS code G0378 are billed–

* On the same day as HCPCS code G0379; or

* On the same day or the day after CPT codes 99205 or 99215 and

2) There is no service with SI=T on the claim on the same date of service or 1 day earlier than G0378

8003 Level II Extended Assessment and Management Composite

1) 8 or more units of HCPCS code G0378 are billed on the same date of service or the date of service after 99284, 99285 or 99291 and

2) There is no service with SI=T on the claim Composite APC Composite APC Title Criteria for Composite Payment on the same date of service or 1 day earlier than G0378.

0034 Mental Health Services Composite

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Medical Billing Modifier Guide

CPT modifiers update

Key Takeaways:

Understanding CPT codes is essential for accurate medical billing and coding.
CPT code 99284 represents an emergency department visit with a detailed history, examination, and moderate complexity medical decision making.
Clean claims are crucial for timely reimbursement and effective revenue cycle management.
Utilizing electronic billing software can streamline the coding and claims process and improve accuracy.
Outsourcing billing services to managed billing providers like Medical Bill Gurus can optimize coding and increase clean claims.

Understanding CPT Codes in Medical Billing

When it comes to medical billing, CPT codes are crucial for accurately describing and billing for services rendered in the healthcare field. CPT, or Current Procedural Terminology, codes cover a wide range of services, including diagnostic testing, procedures, evaluations, and ancillary services. These codes play a vital role in healthcare coding and ensure that healthcare providers receive appropriate reimbursement for the services they provide.

The complexity of a CPT code is determined by the level of detail in the history, examination, and medical decision making. This level of detail reflects the intensity and complexity of the service provided. For emergency department visits, the evaluation and management of patients is captured using CPT codes 99281-99285.

Let’s take a closer look at CPT codes and their significance in medical billing:

Accurate Description: CPT codes provide a standardized way to describe various medical services, ensuring clarity and consistency in medical billing.
Billing for Services Rendered: CPT codes enable healthcare providers to bill for the specific services they have provided to their patients, allowing for proper reimbursement.
Outpatient Services: CPT codes cover a wide range of outpatient services, including office visits, procedures, laboratory tests, radiology services, and more.

Understanding and correctly applying the appropriate CPT code is essential for healthcare providers to ensure accurate billing and maximize reimbursement for the services they provide.

Take a look at the table below for an overview of the CPT codes commonly used for emergency department visits:

Understanding the appropriate CPT code, such as code 99284, is vital for accurately billing emergency department visits and ensuring proper reimbursement. By utilizing the right codes and documenting services accurately, healthcare providers can navigate the complexities of medical billing and maximize their revenue.

The Importance of Clean Claims for Reimbursement

Clean claims are an essential aspect of the healthcare billing process, ensuring timely reimbursement and effective revenue cycle management. They refer to claims that are approved after the first submission, without any errors or discrepancies that may lead to claim denials.

Insurance companies are rigorous in their assessment of claims, scrutinizing them for inaccuracies, missing information, or incorrect coding. Even a minor mistake can result in claim denials and delayed reimbursement, negatively impacting a provider’s cash flow and overall revenue. Therefore, perfecting the claims process is crucial to minimize denials and optimize reimbursement.

Accurate coding plays a vital role in generating clean claims. Properly assigning CPT codes, such as CPT code 99284 for emergency department visits, is imperative to ensure the claim reflects the services provided accurately. Using the correct CPT code increases the chances of claim approval and appropriate reimbursement.

Insurance billing for healthcare services involves navigating complex rules, regulations, and policies set by payers. It requires extensive knowledge of coding guidelines and comprehensive documentation of services provided. Therefore, providers must stay updated with the latest coding requirements and guidelines to maximize the chances of clean claims and avoid claim denials.

To illustrate the importance of clean claims, consider the following data:

These statistics highlight the significant impact that clean claims have on a provider’s financial stability. By avoiding claim denials and submitting clean claims, providers can shorten reimbursement cycles and maintain a steady cash flow for their practice.

Understanding CPT Code 99284

CPT code 99284 specifically represents an emergency department visit for the evaluation and management of a patient. It requires a detailed history, a detailed examination, and moderate complexity medical decision making. This code is typically used when the presenting problem is of high severity but does not pose an immediate significant threat to life or physiological function. Providers must accurately document and code the elements required for CPT code 99284 to ensure proper billing and reimbursement.

Elements of CPT Code 99284

Detailed History: Providers must gather relevant information about the patient’s condition, including their symptoms, medical history, and any potential risk factors. This detailed history helps determine the severity of the presenting problem.
Detailed Examination: A thorough physical examination is performed to assess the patient’s condition. This includes evaluating vital signs, performing diagnostic tests, and conducting a comprehensive assessment of the patient’s overall health.
Moderate Complexity Medical Decision Making: Providers must analyze and evaluate the patient’s information, including their history, examination findings, and any diagnostic results. Based on this assessment, they make a medical decision regarding the appropriate course of action, which may include further testing, treatment, or referrals.

Accurate and comprehensive documentation is essential for successful billing and reimbursement using CPT code 99284. Providers need to ensure they include relevant details, such as the patient’s chief complaint, history of present illness, review of systems, physical examination findings, and medical decision-making process. Properly coding CPT code 99284 reflects the complexity and severity of the visit, enabling providers to receive appropriate reimbursement for their services.

Other Codes Related to CPT Code 99284

CPT code 99284 is part of a set of codes that describe different levels of evaluation and management for emergency department visits. These codes include:

These codes encompass a range of problem severities and complexity levels, allowing healthcare providers to accurately document and bill for emergency department visits. It is essential to choose the appropriate code based on the level of evaluation and management required for each patient encounter.

Improving Coding and Claims Process for CPT Code 99284

At our practice, we understand the importance of efficient coding and a streamlined claims process. To enhance our use of CPT code 99284 and ensure clean claims, we have implemented state-of-the-art electronic billing software. This software has revolutionized our billing procedures, resulting in improved coding accuracy and increased successful claim submissions.

Our electronic billing software offers a range of features that have significantly benefited the coding and claims process:

Electronic billing for primary and secondary insurances: We can conveniently submit claims electronically, eliminating the need for paper claims and reducing the chances of errors during manual submission.
Claim status checks: With just a few clicks, we can easily track the status of submitted claims. This allows us to promptly address any issues or follow up on pending payments.
Payment and authorization tracking: Our software provides a centralized platform to monitor payments and authorizations, ensuring we stay on top of our revenue cycle management.

Implementing electronic billing software has relieved the coding pressure on our team, allowing us to redirect our focus towards delivering exceptional patient care. Our staff can confidently code for CPT code 99284, knowing that our software streamlines the process and increases the chances of clean claims and optimized reimbursement.

Managed Billing Services for Mental Health Providers

In addition to electronic billing software, mental health providers have the option to outsource their billing needs to managed billing services. These services, offered by companies like Medical Bill Gurus, provide specialized expertise in medical coding, billing, and claims management. By partnering with a reliable billing company, mental health providers can ensure accurate coding for CPT code 99284 and other related codes, increasing the chances of clean claims and optimized reimbursement.

Benefits of Managed Billing Services

Outsourcing billing needs to a managed billing service can offer numerous benefits for mental health providers:

Expertise: Managed billing services have extensive experience in medical coding and billing, ensuring accurate and compliant coding for CPT code 99284 and other relevant codes.
Efficiency: Dedicated billing professionals streamline the billing process, allowing providers to focus on patient care rather than administrative tasks.
Claims Management: Managed billing services handle the entire claims process, from submission to follow-up, reducing the burden on mental health providers.
Optimized Reimbursement: By ensuring accurate coding and clean claims, managed billing services maximize reimbursement for mental health services, improving financial outcomes.

By utilizing managed billing services, mental health providers can navigate the complexities of medical coding and billing, ultimately enhancing their revenue cycle management and practice efficiency.

Table: Comparison of Managed Billing Services

Table Note: Comparison of the benefits offered by different managed billing services for mental health providers.

Challenges and Consequences of Incorrect Coding

Incorrect coding can have serious repercussions, leading to claim denials, penalties, and alterations in reimbursement rates. Insurance companies and payers are vigilant in detecting potential fraudulent claims and are quick to deny those that are not accurately coded. The consequences of incorrect coding can range from delays in payment to audit requests and financial complications for healthcare providers.

When claims are inaccurately coded, they are more likely to be denied by insurance companies, resulting in a loss of revenue for the provider. Denied claims can lead to delays in reimbursement, affecting the cash flow of the practice and hindering its financial stability. Additionally, repeated claim denials can harm the provider’s reputation and credibility.

Insurance companies may also impose penalties on providers who consistently submit claims with coding errors. These penalties can further impact the provider’s bottom line and their ability to provide quality care to patients. Moreover, inaccurate coding can result in alterations to reimbursement rates, ultimately affecting the financial viability of the practice.

Another consequence of incorrect coding is the increased likelihood of an audit. Insurance companies and government agencies, such as Medicare, regularly conduct audits to ensure the accuracy and integrity of claims submitted. An audit can be a time-consuming and stressful process for providers, requiring them to provide extensive documentation and evidence to justify their coding decisions.

To mitigate the challenges and consequences of incorrect coding, providers must prioritize coding accuracy and take necessary measures to ensure compliance with coding guidelines. This includes staying updated on coding changes and seeking continuous education and training to enhance coding proficiency. Investing in reliable coding resources and leveraging technology, such as electronic billing software, can also improve accuracy and streamline the coding process.

Compliance with Insurance Company Rules and Guidelines

When it comes to proper billing and coding, insurance companies like Blue Cross and Blue Shield have strict rules and guidelines in place. As healthcare providers, we must ensure compliance with these requirements to avoid claim denials and potential liability. One important aspect of compliance involves understanding the restrictions on using CPT codes for specific places of service.

For instance, CPT codes 99281-99285 are designated for emergency department visits and should not be used for other places of service. It’s crucial to accurately select the appropriate CPT code based on the location where the patient is treated. Failure to follow these guidelines can result in claim denials, delayed reimbursement, and potential financial consequences.

Understanding insurance company rules and billing requirements is essential for healthcare providers to navigate the complex landscape of medical coding and billing. By staying compliant, we can ensure that our claims are processed smoothly and that we receive timely reimbursement for the services we provide.

CPT Code Restrictions and Emergency Place of Service

One key aspect of compliance with insurance company rules is adhering to CPT code restrictions based on the place of service. As mentioned earlier, CPT codes 99281-99285 are specifically meant for emergency department visits. These codes capture the level of evaluation and management provided during these critical situations.

It’s important to note that using these codes for other places of service, such as outpatient clinics or non-emergency settings, can lead to claim denials and potential audit scrutiny. Insurance payers require accurate coding that reflects the actual services rendered in each specific location.

Here is a table illustrating the CPT code restrictions based on the place of service:

By understanding and adhering to these CPT code restrictions, healthcare providers can maintain compliant billing practices, reduce the risk of claim denials, and ensure accurate reimbursement for the services they provide.

Image: An illustration depicting the importance of adhering to CPT code restrictions based on the place of service.

Best Practices for Mental Health Coding and Billing

Mental health providers often have minimal training in medical coding and billing practices. This can lead to inaccuracies in coding and billing, resulting in claim denials and financial complications. To ensure accurate coding and streamlined billing practices, mental health providers should consider implementing the following best practices:

1. Medical Coding Training

Investing in medical coding training for staff members can greatly enhance coding accuracy and understanding. By equipping the team with comprehensive knowledge of mental health coding practices, providers can ensure accurate code selection, proper documentation, and improved compliance with billing requirements. This training may cover topics such as CPT codes related to mental health services, evaluation and management coding, and the use of modifiers specific to mental health.

2. Outsourcing to a Third-Party Billing Agency

Outsourcing coding and billing to a third-party agency specialized in mental health services can be a viable solution for providers facing administrative burdens and seeking expert assistance. A reliable third-party billing agency, such as ABC Billing Services, provides access to experienced professionals who possess in-depth knowledge of mental health coding and billing practices. By leveraging the expertise of these professionals, providers can optimize clean claims, increase reimbursement rates, and reduce claim denials.

In addition to these best practices, mental health providers should prioritize ongoing professional development and stay updated with the latest coding changes and industry guidelines. Collaboration with a reputable medical billing company, like ABC Billing Services, can provide continuous support and ensure compliance with regulatory requirements in mental health coding and billing practices.

Coding Documentation Requirements for CPT Code 99284

Accurate coding is essential for proper reimbursement when using CPT code 99284. To ensure accurate coding, detailed documentation of the patient’s history, examination, and medical decision making is required. Each of these components must be thoroughly documented to support the level of complexity required for this code.

When documenting the patient’s history, include a detailed account of the patient’s current condition, including the onset, duration, and any relevant factors. Document any past medical history, including previous treatments, surgeries, or chronic conditions that may impact the current visit.

The examination documentation should include a comprehensive assessment of the patient’s vital signs, physical appearance, and any relevant findings from the examination. Any tests, procedures, or diagnostic results should also be documented.

Medical decision making is a critical aspect of coding documentation for CPT code 99284. Document the thought process behind the diagnosis and treatment plan, including the assessment of risks and benefits. Include any consultations or referrals made and document any medications prescribed or administered.

Accurate coding documentation is crucial for generating clean claims and optimizing reimbursement. Providers must ensure that the documentation aligns with the requirements of CPT code 99284 to avoid claim denials and revenue loss.

Benefits of Using Medical Bill Gurus for Billing Services

When it comes to navigating the complexities of healthcare coding and insurance billing, medical providers need a reliable partner to ensure accurate coding and optimized reimbursement. That’s where Medical Bill Gurus come in. We offer comprehensive billing services for healthcare providers, including mental health professionals, with expertise in medical coding, insurance billing, and claims management.

With our in-depth knowledge of the industry, we understand the intricacies of billing for CPT code 99284 and other related codes. Our team works with all insurance payers, including Medicare, to ensure that your coding is accurate and compliant. We know the specific requirements and guidelines of each payer, allowing us to maximize your reimbursement rates.

By choosing Medical Bill Gurus as your billing services partner, you can benefit from our streamlined billing process. Our advanced technology and automated systems enable us to efficiently handle your billing needs, saving you time and ensuring accuracy. By outsourcing your billing to us, you can focus on what matters most – delivering quality care to your patients.

Why Choose Medical Bill Gurus for Your Billing Services?

Expertise in medical coding: Our team of experienced coders ensures that your claims are accurately coded, minimizing the risk of claim denials and optimizing your revenue.
Insurance payer knowledge: We have extensive knowledge of insurance payer guidelines and requirements, allowing us to navigate the complexities of insurance billing with ease.
Comprehensive claims management: Our end-to-end claims management process ensures that your claims are submitted accurately and timely, maximizing your chances of clean claims approval.
Automated systems: Our advanced technology automates mundane tasks, freeing up your staff’s time and improving coding accuracy.
Focus on compliance: We stay up-to-date with the latest industry regulations and coding updates, ensuring compliance and minimizing the risk of penalties or audit requests.

Partnering with Medical Bill Gurus allows you to optimize your revenue cycle and improve your bottom line. With our expertise in healthcare coding and billing, you can trust us to handle your billing needs efficiently and effectively.

With Medical Bill Gurus as your billing services partner, you can ensure accurate coding, minimize claim denials, and maximize reimbursement rates. Let us handle your billing needs so that you can focus on providing exceptional care to your patients.

Accurate coding and clean claims are essential for mental health providers to optimize reimbursement in the healthcare industry. Understanding the requirements and documentation for CPT code 99284 is crucial when billing for emergency department visits. Providers can greatly improve coding accuracy and streamline the billing process by utilizing electronic billing software or outsourcing their billing services.

By partnering with a reliable billing company like Medical Bill Gurus, mental health providers can focus on delivering quality care to their patients while ensuring accurate coding and maximizing their revenue cycle. Medical Bill Gurus offers comprehensive billing services, including expertise in medical coding, insurance billing, and claims management. Their streamlined billing process and experience with all insurance payers, including Medicare, ensures accurate coding and optimized reimbursement for mental health providers.

Optimizing the coding and claims process for CPT code 99284 through accurate documentation, electronic billing software, or outsourcing billing services can lead to increased clean claims and improved hospital reimbursement. Providers should prioritize clean claims and accurate coding to minimize claim denials, penalties, and financial complications. By following best practices and partnering with trusted billing services, mental health providers can navigate the complexities of medical billing and focus on their core mission of delivering excellent patient care.

What is CPT code 99284?

CPT code 99284 represents an emergency department visit for the evaluation and management of a patient. It requires a detailed history, examination, and moderate complexity medical decision making.

What are CPT codes used for in medical billing?

CPT codes are used to accurately describe and bill for services provided in the healthcare field, including diagnostic testing, procedures, evaluations, and ancillary services.

Why are clean claims important for reimbursement?

Clean claims, which are approved after the first submission, are crucial for timely reimbursement and effective revenue cycle management.

What are the other codes related to CPT code 99284?

Other codes related to CPT code 99284 include CPT code 99281, 99282, 99283, and 99285, which capture different levels of evaluation and management for emergency department visits.

How can providers improve their coding and claims process for CPT code 99284?

Providers can improve their coding and claims process by utilizing electronic billing software, which can streamline the billing process and increase coding accuracy.

Are there managed billing services available for mental health providers?

Yes, managed billing services like Medical Bill Gurus offer specialized expertise in medical coding, billing, and claims management for mental health providers.

What are the consequences of incorrect coding?

Incorrect coding can lead to claim denials, penalties, alterations in reimbursement rates, and other financial complications for providers.

What rules and guidelines should providers comply with when billing CPT code 99284?

Providers should comply with insurance company rules, including restrictions on the use of CPT codes for specific places of service such as the emergency department.

What are the best practices for mental health coding and billing?

Mental health providers can consider investing in medical coding training for their staff or outsourcing their coding and billing needs to a third-party agency to ensure accuracy and efficiency.

What documentation is required for accurate coding of CPT code 99284?

Providers must ensure proper documentation of the patient’s history, examination, and medical decision making to support the level of complexity required for CPT code 99284.

How can Medical Bill Gurus benefit healthcare providers?

Medical Bill Gurus offers comprehensive billing services, including expertise in medical coding, insurance billing, and claims management, to maximize reimbursement for healthcare providers.

Why is accurate coding and clean claims important in medical billing?

Accurate coding and clean claims are essential for optimal reimbursement and revenue cycle management in the healthcare industry.

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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.

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.)

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

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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.

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UHC Coding Policy for Emergency Departments (ED) Facility Evaluation and Management (E&M) 2023

Understanding the difference between hcpcs codes and cpt codes in medical billing, understanding the top 10 medicare advantage plans.

A Quick Guide To Identifying Level-4 Visits

Evaluation and management (E/M) service coding and documentation has to be the issue that physicians despise reading about the most. As we all understand, the “guidelines” for code and documentation are a tangle of regulations that encourage down coding by keeping the laws unclear and the severe penalties. The “new framework” for documentation standards, which is anticipated to be issued later this year, may or may not clarify the regulations. So far, revision hasn’t made the process any simpler to use.

A Quick Guide To Identifying Level-4 Visits (99214)

According to CPT, 99214 is recommended for an “office or another outpatient visit for assessing and caring of an established patient, which needs at least two of these three essential aspects: a complete history, a thorough analysis, and medical decision making of varying capabilities.

99214 General Guidelines

Consider 99214 in any of the following circumstances:

If the patient develops a new Problem that might result in substantial morbidity if left untreated.
If the patient has three or more previous issues.
If the patient develops a new issue that necessitates a medication.
If the patient has three stable problems that need medication renewals, or if the patient has one steady-state and one poorly managed problem that requires drug refills or changes.

Documentation

To keep our use of level-4 codes more uniform and decrease the amount of time spent on coding, I created the “Level 4 Reference Card” for myself, my colleagues, and our residents. The card’s front includes the primary requirements that your documentation must fulfil to classify a visit as a 99214 (any two of the following: a complete history, a detailed exam, and moderately tricky decision making), and it describes the materials that must be documented to satisfy each requirement. It also has a box that describes the requirements for a level-4 visit with an existing patient (99214) vary from a level-4 appointment with a new patient (99204). The reference card can be used in at least two main ways: First, using the card attached to the wall where you dictate, you may follow along while you write your note, ensuring that your dictation contains all of the information that suggests your level-4 code option. You can also use the reference card as a guide for performing internal audits of other doctors’ records.

Internal coding and documentation audits may strike you in the same way dental appointments hit the general public, but don’t dismiss their importance. Every doctor in our 22-person group evaluates five dictations every month, and every physician is a better coder. In our practice, the physicians are expected to be the coding specialists. It’s also crucial to enhance the quality of your coding. We’ve discovered that adding the CPT codes to the bottom of all our dictations and highlighting them on the superbills is a valuable tip. As a result, we may conduct our mini-audits to confirm that our documentation validates our coding when we receive our dictations. If we discover that we have under coded, we usually write off the penalty. If we find out that we have coded too high, we may file a corrected claim (and our procedure is to hold all our level-4 and -5 Medicare charges until the dictation has been reviewed). The actual value of this practice is that it helps all of us better coders.

Level 4 Visits With New Patients

A detailed history and physical exam are required for a 99214, whereas a complete history and physical exam are required for a 99204. In terms of documentation, the discrepancies are reflected in four ways:

All three essential requirements (history, physical exam, and medical decision making) must be satisfied for a 99204. Only two of the three basic requirements are required for a 99214.
The system review for a 99204 must encompass at least ten systems or bodily parts. A 99214 requires only two studies.
The previous family and societal history for a 99204 must include all three sectors. A 99214 requires one area.
The physical test for a 99204 must encompass at least 18 shots from at least nine systems or physical locations. At least 12 rounds from at least two systems or bodily areas are required for a 99214.

When we neglect to follow the guidelines, we may fail to include information collected during the visit in the patient record – information that we believed was important due to the patient’s condition.

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Why Did My Emergency Room Visit Cost So Much?

Emergency room visits are notoriously expensive. Just a few hours in the ER can cost you thousands of dollars, with or without insurance.

But how is your ER visit cost calculated, and how can you tell whether your hospital bill is correct?

We scored some insider tips from Goodbill medical coding expert Christine Fries, who has analyzed thousands of ER hospital bills for accuracy. Here are answers to frequently asked questions we get from Goodbill customers about how to understand and vet ER visit costs.

Why did I get 2 bills for my ER visit?

Patients are usually surprised when their first ER hospital bill is quickly followed by a separate hospital bill with similar-sounding charges but different amounts. This is normal and a byproduct of how hospitals bill patients for the services rendered at the hospital, Fries says.

The institutional bill, also known as the facility bill, charges you for the procedures, tests, and administrative costs from the hospital.

The professional bill, also known as the physician bill, charges you for the work and time of the physician who treated you. This generally includes services from doctors, anesthesiologists, or specialists who are affiliated with the hospital but aren’t employed by the hospital.

Expect to get two bills from your ER visit — one for facility charges, and the other for professional or physician charges.

For more information on the different types of hospital bills, see our itemized bill guide . Goodbill currently helps patients negotiate institutional bills, not professional bills, so our guidance below pertains to institutional bills only.

My diagnosis turned out to be minor. Why was I charged so much?

It’s important to remember that your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis, Fries says.

When a patient walks into the emergency room complaining of chest pains, for example, the hospital’s objective is to run tests and administer procedures that can help rule out life-threatening conditions. Even if the doctor ends up discharging the patient with a non life-threatening diagnosis like indigestion, the hospital has already spent the resources to rule out more severe possibilities like a heart attack.

Your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis.

“Look at your symptoms first, not what you were diagnosed with,” Fries says. “The level of your ER visit is guided by the symptoms you described, and by the tests the hospital thought were needed based on those symptoms.”

Why was I charged for an ‘ER Visit Level’ 3, 4, or 5? Is this based on severity?

Hospitals will bill you for a line item called “ER Visit Level” that is based on the complexity of your treatment. ER visit levels range from 1-5: ER visit level 1 is the most mild, while ER visit level 5 is the most severe. The level also determines how much the hospital can charge you, from least expensive to most expensive. You may sometimes hear ER visit levels described by their corresponding Current Procedural Terminology (CPT) codes of 99281, 99282, 99283, 99284 and 99285.

To decide the proper ER visit level, hospitals typically follow certain guidelines from the American College of Emergency Physicians (ACEP) . ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says.

“Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there,” Fries says.

The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common.

Here’s a simple rule of thumb for determining whether your ER visit level was correctly assigned.

ER Visit Level 4

‍ An ER visit level 4 typically requires a minimum of two diagnostic tests — like a lab plus an EKG, or a lab plus an X-ray. Or, any administration of fluids through IV will automatically qualify your visit as an ER visit level 4.

ER Visit Level 5

‍ An ER visit level 5 typically requires a minimum of three diagnostic tests — for example, a lab plus EKG and X-ray. Or, any type of imaging scan like a CT scan or MRI where a patient must ingest or be injected with contrast material, will automatically qualify your visit as an ER visit level 5.

‍ I’m not pregnant. Why did I get charged for a pregnancy test?

Many female patients get frustrated when they’re charged for a pregnancy test, even when they’re absolutely certain they’re not pregnant. But this is standard practice and a way for hospitals to protect against unknown pregnancies, Fries says.

If you’re an adult pre-menopausal female, you can count on being asked to do a urine or blood pregnancy test before the hospital will treat you. It’s too risky to both the patient and hospital to administer injections, scans or drugs in the off chance that a patient is unknowingly pregnant.

If you're a female, expect to get a pregnancy test during your ER visit — even if you're not pregnant.

On your itemized ER bill, your pregnancy test will usually show up with a description like “human chorionic gonadotropin (hCG),” which is the hormone being tested. This charge will generally fall under the CPT codes 84702 or 84703 if it’s a blood test, or 81025 if it’s a urine test.

What are some other common ER services I might see on my hospital bill?

Here are a few common procedure names that often show up in your ER visit costs, and what they mean in plain English:

Metabolic panel

‍ This is a bundle of lab tests run from a single blood draw. Patients may get a “basic” metabolic panel under CPT code 80048, or a “comprehensive” metabolic panel under CPT code 80053. These panels cover a set of individual tests that might otherwise be individually charged. For example, a “comprehensive” metabolic panel must include testing for all of the following:

Carbon dioxide
Phosphatase, alkaline
Transferase, alanine amino
Transferase, aspartate amino
Urea nitrogen

Venipuncture

‍ Any time you get your blood drawn through a needle, this charge under CPT code 36415 is the line item that bills you for the needle.

‍ This test under CPT code 83690 measures your levels of lipase, which is an enzyme that helps break down fat in your intestines. Your lipase levels may be elevated if you have pancreatitis, which is an inflammation of the pancreas gland.

What are some ER visit cost errors I should look out for?

When analyzing a patient’s ER visit costs for errors, Fries says she goes straight to one place first: Hydration services. If you recall being administered fluids through an IV bag, chances are you got hydration services during your ER visit.

“Hydration services should always be questioned,” Fries says.

Coding guidelines require that the two CPT codes for this service, 96360 and 96361, meet a minimum time requirement of 31 minutes in order for one unit to be billed. These 31 minutes must also be “stand alone” — meaning that the administration of the service cannot overlap with any other type of infusion service. Often, hospitals don’t meet these requirements, rendering the charge unbillable.

Hydration services are a common source of errors in ER hospital visit costs. You can tell if you're being overcharged by checking your medical record.

To verify whether you’re being charged properly, you’ll need your medical record, Fries says. Look for hydration service “start” and “stop” times, which are usually included in the Medication Administration Report (MAR) section of your record. If the hydration service duration is less than 31 minutes of standalone time, you have a strong case to dispute the charge with your hospital. To find out how to get your medical records online, visit our Medical Records guide .

I don’t see any CPT codes on my bill. How can I get them?

CPT codes are the common language used across all hospitals to describe a certain procedure. They’re what enables our medical coders at Goodbill to analyze hospital bills for errors, line item by line item. They also help us compare prices apples-to-apples across hospitals.

CPT codes are the standard language used to describe a certain procedure across all hospitals. They're key to helping you identify errors or inflated charges in your ER hospital bill.

Unfortunately, the hospital bill you get in the mail is most likely a consolidated summary of your ER visit costs and won’t include CPT codes. You’ll need an “itemized bill” from your hospital to get a line-by-line breakdown of each charge, complete with the CPT code and cost.

The good news is that you’re legally entitled under HIPAA to get access to this information. To learn more about your patient rights and how to obtain your itemized bill, check out our Patient Right of Access guide .

Are there other topics you’d like us to cover? Email us at [email protected] and let us know.

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Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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IMAGES

Cheat Sheet Free Printable Cpt Codes List Pdf
2021 E/M Changes to Outpatient Visits Part 2
CPT code 99284 : Use of Emergency Department Level 4
Chart, Code, and Bill for E&M Office Visits
Coding Level 4 Office Visits Using the New E/M Guidelines
Emergency Department Coding Cheat Sheet 2020

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COMMENTS

Emergency CPT
• An emergency department visit (CPT code 99284 or 99285) or • A clinic visit (CPT code 99205 or 99215); or • Critical care (CPT code 99291); or • Direct admission to observation reported with HCPCS code G0379, must be reported on the same date of service as the date reported for observation services. b.
Coding Level 4 Office Visits Using the New E/M Guidelines
The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare ...
Understanding 99284 CPT Code For ER Visits
Explore the essentials of the 99284 CPT code, detailing what it means for a level 4 emergency department visit and billing practices. ... Proper documentation and coding of emergency department visits using CPT code 99284 can lead to optimized reimbursement rates, ensuring adequate compensation for the level of care provided.
CPT Code 99284: ER Visit Billing Guide
Navigate the complexities of billing a level 4 ER visit with our guide on cpt code 99284, ensuring accurate hospital reimbursement. ... CPT Code Level of Complexity; 99281: Simple Problem, Focused History, Examination, and Medical Decision Making: 99282:
Coding and Billing Guidelines for Emergency Department
Coding & Billing Guidelines. Emergency Department (ED) Evaluation and Management (E/M) codes are typically reported per day and do not differentiate between new or established patients. There are 5 levels of emergency department services represented by CPT codes 99281 - 99285. The ED codes require the level of Medical Decision Making (MDM) to ...
Was that a level 4 E/M visit? Find the answer in just three ...
The new rules should make it easier to avoid under-coding level 4 visits — a common and costly mistake. In fact, most level 4 visits can now be identified by asking just three questions: 1. Was ...
A Simplified Explanation of Emergency Department E/M Coding
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.
Emergency Department Visits
99283 (G0382) Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical-decision making. Any interventions from above, plus any below: Receipt if EMS/Ambulance patient. Heparin/saline lock. One Nebulizer treatment.
A Quick-Reference Card for Identifying Level-4 Visits
KEY POINTS: A few simple rules of thumb can help you remember when a code of 99214 might be indicated. The author uses his reference card as a reminder of what must be documented to support a ...
Emergency Department Visits
Emergency Department Visits. Definition. 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 ...
PDF Emergency Department Visit Leveling
C. Leveling Adjustments. When a physician bills a Level 4 (99284) or Level 5 (99285) emergency room E/M service, with a diagnosis indicating a lower level of acuity, complexity, or severity, the service will automatically be reimbursed at the Level 3 (99283) reimbursement rate. The submitted procedure code will be changed to 99283 in the claims ...
A Quick Guide To Identifying Level-4 Visits
99214 CPT Code Level 4 medical billing medical Coding. The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30-39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45-59 minutes. Many EHRs have time calculators that will show the amount of time you have had the patient ...
2023 Emergency Department Evaluation and Management Guidelines
In the emergency department, time will be utilized when assigning critical care codes 99291-99292, but NOT for ED E/M codes 99281-99285. The long-standing policy for time in relation to the ED E/M codes has not changed.
Approach to Emergency Department Coding FAQ
Below is a partial listing of some of the CPT codes commonly used by emergency physicians. 1. Emergency Department Evaluation & Management (E/M) Codes (99281-99285) This code set was developed in 1992 for use by emergency medicine physicians. Five (5) different levels of service are used depending on the nature of the presenting complaint to ...
2023 AMA CPT Documentation Guideline Changes for ED E/M Codes ...
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. ... The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not ...
PDF Emergency department visit place of service restriction
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 facility must be available 24 hours a day. Based on this definition, codes 99281-99285 will be denied provider liable as incompatible if submitted with any ...
Emergency Department Services CPT ® Code range 99281- 99288
Emergency Department Services CPT ® Code range 99281- 99288. Emergency Department Services CPT. ®. Code range 99281- 99288. The Current Procedural Terminology (CPT) code range for Emergency Department Services 99281-99288 is a medical code set maintained by the American Medical Association.
PDF Coding Level 4 Office Visits Using the New E/M Guidelines
Coding Level 4 Ofice Visits Using the New E/M Guidelines. Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions ...
2 Best Practices to Improve Emergency Coding
The nature of a patient's presenting problem is key to determine the appropriate level of risk under MDM. Choosing between 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity and 99284 Emergency ...
Why Did My Emergency Room Visit Cost So Much?
ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says. "Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there," Fries says.
PDF Evaluation and Management Coding for Emergency Medicinefor ...
HPI flushes out the chief complaint in grea t er d e t a il. There are two types of HPI identified for the purpose of coding. A brief HPI consists of 1-3 elements (99281-99283) An extended HPI consists of at least 4 elements (99284-99285) 27. Brief- 32 year old male with left shoulder. injury, occurred 4 hours ago.
A Step-by-Step Time-Saving Approach to Coding Office Visits
Step 1: Total time. Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if ...
Hello GPT-4o
Prior to GPT-4o, you could use Voice Mode to talk to ChatGPT with latencies of 2.8 seconds (GPT-3.5) and 5.4 seconds (GPT-4) on average. To achieve this, Voice Mode is a pipeline of three separate models: one simple model transcribes audio to text, GPT-3.5 or GPT-4 takes in text and outputs text, and a third simple model converts that text back to audio.
ED Facility Level Coding Guidelines
The facility code level assigned is always the highest level at which a minimum of one "Possible Intervention" is found. An example of correct usage of this "Guideline" follows: Example # 1. A 48 year old woman with a prior history of a myocardial infarction and atrial fibrillation comes to the emergency department complaining of pelvic pain.
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