ED Coding and Reimbursement Alert

Check out the new rules for 99281-99285.

Coding for ED evaluation and management (E/M) services is about to undergo a seismic shift. Experts expect the after effects of the changes to stick around for a long time, as coders and payers get used to a new landscape of code selection.

“We are excited to embrace what will most likely be a once-in-a-career update to evaluation and management documentation guidelines for emergency medicine,” says Sarah Todt, RN, CPMA, CPC, CEDC, CPCO, executive director, revenue integrity at LogixHealth in Bedford, Massachusetts.

Read on to check out just what’s changing when you code your first ED E/M after the changes take effect on Jan. 1, 2023.

ED Code Changes Similar to Office E/M Changes … but Different

ED coders might have noticed that in 2021, there were significant changes in the descriptors for office/outpatient E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

CPT^® overhauled the descriptors for each of these codes, eliminating the language about three key components: history, examination, and medical decision making (MDM). In place of the three key components, CPT^® made time or MDM (one or the other, not both) the sole deciding factor in E/M level selection.

The ED E/M revisions are reminiscent of those changes, with one big difference: the ED E/M codes will only allow coders to use MDM as the determining factor in code selection. This isn’t to say that you don’t need to document history or exam; but you don’t have to reach a certain level of history or exam (problem focused, straightforward, low, etc.) in order to select an ED E/M level. As the descriptor indicates, history and exam need to be “medically appropriate” for the encounter.

Here’s What CPT^® Is Deleting

CPT^® 2023 will delete the descriptors for the following codes:

• 99281 (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...)
• 99282 (… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity...)
• 99283 (… An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity...)
• 99284 (… A detailed history; A detailed examination; and Medical decision making of moderate complexity...)
• 99285 (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...)

Here’s What CPT^® Is Adding

CPT^® 2023 will add these descriptors for the above-listed codes:

• 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional)
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making)
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making)
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making)
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making)

New Descriptors Provide Clarity, but Adjustment Could Hurt

Overall, experts think that the new 99281-99285 descriptors will positively impact ED coding — but perhaps not in the short term.

“We are grateful of the changes to the history and exam requirements are much more in line with clinical medicine,” explains Todt. “Additionally, we are looking forward to a more consistent approach to medical decision making.”

The adjustment won’t be easy for everyone, though. “The biggest challenge is letting go of the old approach since most in emergency medicine have been following the same guidelines for over 25 years,” according to Todt.

“Overall, I think I feel positive about these changes as they do away with some of the crazy documentation requirements: e.g., complete ROS [review of systems] in the ED,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “But I don’t think it will be intuitive for ED providers to document this way and that could have a strong negative impact on hospital and medical practice revenue.”

Bucknam says coders and provider should be patient, as coding strictly by MDM level won’t be easy at first. “I think there will be a lot of pushback by providers and coders, and provider educators are going to need to be ready to answer questions and adjust templates in order to avoid the most negative impacts these changes could have,” she explains.

In order to be as prepared as possible for the 2023 ED E/M changes, Bucknam recommends these three steps:

1. “First, coders must be educated as early as possible and should have sample documentation to practice with so that they can be proficient with the rules change.
2. “Second, I strongly recommend that coders develop coding tools that will allow them to identify all of the components that have been met or missed in the documentation, and they should use those tools until they are comfortable that they have expertise in finding the information they are looking for.
3. “Third, it will be important that templates are updated in a timely fashion to help providers capture the information needed to code under these new rules. Templates have become the bedrock of our documentation over the years and bad templates may have a huge negative impact on practices when these changes go into effect.”

Finding Prep Time Vital to Early Success

Bucknam also recognized the strain that training can have on coders — particularly ED coders and other hospital-based specialties. Practices need to find methods to make sure everyone is properly trained before January 1.

For ED coders, Bucknam feels “it can be very hard to schedule training time — and, in my opinion, online training only is not adequate. Coders and provider educators need to think about how they will reach these providers and when training can be scheduled, as well as how ongoing feedback will take place for those providers who only work weekends or nights or who have rotating schedules.

“Thoughtful planning will be the key to success.”