Errors in Emergency Department Services

Published 01/23/2020

Palmetto GBA began the prepayment service specific review last fall, which encompasses Current Procedural Terminology (CPT) codes 99281-99285. The frequently noted denial reasons are identified below.

 99281

Emergency department visit 99281 for the evaluation and management of a patient, which requires these 3 key components:

  • A problem focused history;
  • A problem focused examination; and
  • A straightforward medical decision.

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.
The presenting problems range from moderate to high severity with significant threat to life or physiologic function.
  99282

Emergency department visit 99282 is used for the evaluation and management of a patient, which requires the following 3 components:

  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Medical decision making of low complexity.

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 of low to moderate severity.
 99283

 Emergency department visit 99283 is used 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 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 of moderate severity.
 99284

Emergency department visit 99284 is used for the evaluation and management of a patient, which requires the following 3 components:

  • A detailed history;
  • A detailed examination ;and
  • Medical decision making of moderate complexity.

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 of high severity, and require urgent evaluation by the physician(s) or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.
 99285 

Emergency department visit 99285 is used for the evaluation and management of a patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of high complexity.

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 of high severity and pose an immediate significant threat to life or physiologic function.

No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Time also is not a descriptive component for the emergency department levels of E/M services because the emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult for physicians to accurately estimate the time spent face-to-face with each patient.

Note: Face-to-face time refers to the time with the physician ONLY. The time spent by other staff is NOT considered in selecting the appropriate level of service.

Practitioners who use time as the determining factor must ensure:

  • Face-to-face time is  documented in the patient’s record;
  • Documentation must support in sufficient detail the nature of the counseling; and
  • The code selection chosen must reflect the total face-to-face encounter in sufficient detail and be supported clearly in the medical record.

Frequently Noted Denial Reasons:

  • BILER: Submitter documentation reveals that the billing provider is not the rendering provider. 

Education note: Medicare providers are responsible for assuring that the billing provider is the same as the rendering provider and that all services ordered or rendered to Medicare beneficiaries are authenticated by the provider’s signature.

  • DOWNCODED: Payer deems the information submitted does not support he level of service. 

Education note: 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 including the level of visit code billed.

  • KEY COMPONENTS DO NOT SUPPORT E/M LEVEL  BILLED

Education note: 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.

Resources:

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