ED Coding and Reimbursement Alert

The emergency department services code 99285 is the highest level emergency E/M code. It is almost always reserved for treating patients with life-threatening illnesses or injuries.

Like the level five office and outpatient E/M codes (99205, new patient, and 99215, established patient) the 99285 code requires the three components of a comprehensive history, comprehensive examination, and medical decision-making of high complexity.

However, the CPT definition of 99285 includes an interesting phrase: Emergency department visit for the evaluation and management of a patient which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and mental status.

The words in boldface above constitute what is known as the emergency department caveat or acuity caveat. This phrase serves as recognition in CPT that treating a patient suffering from an immediate life-threatening emergency sometimes makes the completion of a comprehensive history and examination very difficult and in many cases clinically inappropriate says Todd Thomas CPC CCS-P president of the Oklahoma City OK chapter of the American Academy of Professional Coders and principal of Thomas and Associates an emergency medicine reimbursement consulting firm also based in that city.

If any of the elements required are limited because the urgency of the patients condition is such that to obtain a complete history or exam would not be appropriate the physician is still able to bill a level five when the situation warrants it Thomas explains.

Payers Differ on Requirements for Billing

In order to use the caveat the physician should document which of the three components are incomplete due to the patients condition he continues. For Medicare experts have recommended that the physician must note that the documentation is lacking due to the patients condition. For commercial carriers if the patients chart treatment and diagnosis indicates the seriousness of the patients presentation then documenting something like history unobtainable due to patient condition may not necessarily be required but it is still a good idea.

In practical terms a busy ED physician with a seriously ill or injured patient might not be extremely concerned with taking the additional time to document what he or she was not able to do.

In almost half of the charge sheets her department gets there is not sufficient documentation for the level of service that should be billed says Barbara Steiner RN ART the ER coding coordinator at Gastonia (NC) Memorial Hospital.

If I have questions or if I feel the diagnosis is life-threatening and the vital signs and all of the symptoms point to that then I call the doctor she explains. If hes not there I call the medical director or whoever and say Hey what went on with this patient?
Payersand some codershave differing opinions on how much of the required components can be omitted and still be covered by the caveat.

According to CPT the caveat applies to any of the key components but some payers only let it apply to the taking of the medical history notes Thomas.

Steiner adds that she considers the caveat only applicable to obtaining the history or covering the required number of elements in the review of systems not to the medical decision-making component.

Perhaps the patient is unconscious. Then you cant do a review of systems she explains. But the physician has to say in her notes Review of systems is unobtainable because the patient is unconscious or something like that. You have to qualify it.

A physical exam would still obviously be performed even on unconscious patients so that would not be included under the caveat Steiner adds. There really is a fine line sometimes between a 99284 (visit) and a 99285 I think. You have to use a lot of judgment about the codes.