Wednesday, January 9, 2013

Emergency CPT codes - 99283, 99284, 99285


99281  (CPT G0380)   Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. 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 self limited or minor.

99282 (CPT G0381)   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 low 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 low to moderate severity.

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.


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)


Indications

Emergency Department services are services provided to a patient in the emergency department or emergency room of a hospital. It is appropriate for the primary physician in the emergency department seeing the patient to use these codes.

Limitations 

If the patient is admitted to the hospital, the admitting physician should code as a hospital admission (99221 - 99223) even if the encounter began in the emergency department.

If the patient is in the ED (ER) for an extended time. i.e., several hours, there should be only one charge for a primary physician for that visit (except as indicated in "Coding Guidelines"). The length of time per se that the patient is in the ED (ER) does not determine the level of service provided. A prolonged visit does not warrant more than one E & M code being submitted for the visit. Additional E & M codes should not be submitted if the patient is seen by more than one primary physician in the emergency department because of a "shift" change.


Prolonged service codes may not be used with emergency department E & M codes.

Emergency Services

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.

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.

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