Evaluation and Management

Emergency Department

  1. When a consultant has seen a patient in the ED and billed an ED code, how are subsequent services billed when the patient is then admitted to inpatient status?

    Answer: The ED consult (billed with an ED code 99281-99285) represents the initial episode of care; when the consultant subsequently sees the patient in the inpatient setting, the services are represented with subsequent hospital care codes 99231-99233.
  2. Do EMTALA rules impact billing for 99281?

    Answer: EMTALA rules require hospitals to provide medical screening, treatment and transfer of individuals with emergency medical conditions (EMCs) or women in labor. Performance of 99281 requires screening and appropriate treatment under the direct supervision of a physician or qualified health care provider on an incident to basis, and this meets the EMTALA requirement as defined in the law.
  3. Please provide examples for appropriate billing of CPT 99281.

    nswer: CPT 99281 may represent straightforward and uncomplicated ED care, not requiring physician or NPP participation. The service requires direct supervision of a physician or NPP, but does not require personal supervision at the bedside.

    Triage evaluations may identify patients whose clinical needs do not require physician or NPP participation. Examples of such services would include, but are not limited to: removal of sutures previously placed by a physician or NPP, replacement of a loose or faulty simple surgical dressing, review of previously issued care or medication instructions for which the patient needs further explanation or support.
  4. When multiple providers perform E/M services for a patient in the ED, is it permissible for more than one provider to take MDM credit for considering inpatient admission?

    Answer: The credit for considering inpatient admission is not limited to the provider who actually initiates the admission order. This credit may be allowed for a consulting provider who evaluates the patient and recommends consideration of inpatient status.
  5. Please define the rules for critical care services in the ED.

    Critical care may be performed in the ED in one of two ways:
    • Critical care for a patient whose clinical status on arrival in the ED demands immediate critical care
    • Critical care for a patient who has received ED care at an earlier point on the DOS and whose condition changes, necessitating critical care delivery. This critical care service may be performed by the same physician/group who provided the earlier ED service, or by a different group. This allowance includes care for the same or different clinical problem for which the patient initially received ED care.

      Note: The sequence of these services must be ED care first, followed by critical care; both services are not payable to the same provider/group when the sequence is reversed.
  6. When a patient is seen first in the ED and then referred to either observation or hospital admission, is the ED code separately payable to the same provider/group?

    Answer: In this scenario, the ED code is not separately payable and all care is considered to be inclusive in the initial observation/hospital admission code series (99221-99223).
  7. Please define the change in 2023 for ED code 99281.

    Answer: As of 1/1/2023, ED code 99281 describes care in the ED that may not require the presence of a physician or other qualified health care provider.
  8. Please define the rules for critical care services performed in the ED by same-specialty providers in the same group.

    Answer: ED and critical care visits may be billed on the same day if performed by same-specialty providers in the same group only when the ED service preceded the critical care service, at a time when the patient did not require critical care intervention. The critical care must be medically necessary and the service separate and distinct from the earlier ED service, with no duplicative elements. In this scenario, the critical care service will require a modifier 25 on the claim.
  9. Please define how time can be used as a factor in billing split/shared E/M services in the emergency department.

    Answer: CPT does not provide timeframes for ED E/M codes and CMS E/M requires that ED billing be based the complexity of MDM.

    Split/shared ED services reflect contributions by both physician and NPP providers and the work performed in formulating a medical decision and plan of care.

    Time is not a level-setting factor for ED services; documentation of service components (history, examination, and MDM) supports the work performed by each contributing provider. Under current CMS E/M guidelines for the ED, a visit may be assessed based on the extent of history and/or examination as medically appropriate, and the complexity of MDM. Time spent performing any of these care elements may be used as a supporting factor in assessing the service, when each contributing provider documents the time he/she spent in the care.
  10. Please define correct coding for an ER service by a consulting provider, when requested by an ER provider.

    CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 30.6.11(A) (1 MB) indicates that “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.” Further, 30.6.11(F) indicates “If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.
  11. NGS guidance for CPT code 99285 states, “The documentation should support that the presenting problem requires the immediate attention of a physician for problems of high severity that pose a significant threat to life or physiologic function." Can a visit be billed as 99285 when the presenting problem is not of high severity, or life-threatening?

    Answer: The presenting problem sets the direction for the level of history, examination and MDM that is medically necessary. A comprehensive history and examination may be “appropriately done” but the medical necessity for these services must correlate to the patient’s clinical status on presentation.
  12. Please clarify coding for minor procedures in the ED. Is an E/M service considered separate from the procedure in this circumstance?

    E/M services in the ED are performed to evaluate the patient’s presenting problem by obtaining a history, performing an appropriate examination and deciding on a medically necessary plan of care. When that plan of care includes a minor procedure (e.g., laceration repair), an E/M service may be billable, but circumstances will dictate the performance of a truly separate E/M service with a modifier 25. Examples of two different circumstances:
    • A patient presents with a laceration of the left hand and a painful and swollen left wrist, both incurred through a fall that was precipitated by an episode of acute vertigo. The patient also has a history of osteoporosis. The patient’s clinical history and HPI supports the need for a physical examination, including a neurological evaluation, and performance of a CT scan of the head, X-ray study of the left wrist and repair of the laceration. The care rendered supports a separately identifiable E/M service, since the provider has performed additional components of care and medical decision making, beyond the laceration repair.
    • A patient presents with a laceration of the left hand, incurred through a fall from slipping on water in the kitchen. The provider assesses the laceration and performs a simple repair. In this scenario, there is no separate service beyond the laceration repair, and the visit would not warrant billing for a separately identifiable E/M.
  13. Can two or more providers bill the ER codes on the same date of service within the same encounter?

    Answer: An ER code may be billed by more than one provider, as long as their Medicare specialties and NPIs are different. This can occur when a patient is seen in the ED by both the ED physician and the patient’s personal physician, or in a circumstance in which the ED physician requests a consultative evaluation by another provider of a different specialty.
  14. Please clarify appropriate billing for patients who have been admitted to a psychiatric service, but are now in an extended ED stay, awaiting a bed.

    Answer: If the patient has been formally admitted to inpatient status (POS 21) and is waiting in the ED for psychiatric bed assignment, physician services are billed with observation/inpatient E/M codes (99221-99223, 99231-99233).

    If the patient remains in outpatient ED status (POS 23), an order for observation will allow the primary care physician to bill for services using the observation inpatient codes (99221-99223 and 99231–99233). Care by consultative providers can be billed using outpatient E/M codes (99201–99205, 99211–99215).

  15. Does the concept of a “new patient” or “new problem” apply to patients treated in the ED?

    The concept of “new” vs. “established” patients does not apply to E/M codes used in the ED. All ED patients, and their presenting problems, are considered as new, regardless of the patient’s history or the examiner’s prior experience with the patient. However, when a provider sees a patient in the ED, subsequent E/M services by that provider in an office setting may be considered as established care.

Reviewed 4/15/2024