ED Coding and Reimbursement Alert

Question: Is there a difference between using CMS and CPT guidelines for E/M services? Many colleagues have told me that there's no difference between the two, and yet others make statements to the contrary. Are the guidelines really that different for E/M services? What guidelines do most emergency physicians use? Do they differentiate how they code for government payers versus commercial payers, or do they follow CMS guidelines for all payers?

Texas Subscriber

Answer: There is no straightforward answer to your question, other to say that CPT and CMS guidelines are not identical. One downside to uniformly following guidelines by the CMS for E/M coding is potentially lost money. CMS evaluates E/M services with a point system, while CPT focuses more on terminology. With room for interpretation, CPT's guidelines could lead you to report codes for higher reimbursement values. The flip side of that coin is that CPT's subjective criteria could make it harder for you to defend high-dollar codes. At least with Medicare, you have a universally recognized system.

The relevant question is this: Do you lose money when you adhere to Medicare's characteristically more conservative guidelines? The answer to this question remains unresolved, but consider the following example, in which Medicare and CPT guidelines produce different E/M codes.

A patient was admitted with chest pain, and the medical decision-making and entire chart meet Medicare's '95 guideline criteria for 99285 (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 patient's clinical condition and/or mental status ...). But the chest pain is described as left-sided and dull, and it lasts only five minutes. In this case, you have only three HPI elements. According to CPT's guidelines, there are no definitions for the levels of HPI.

This case is clearly more than "brief," and most people would consider the three elements as qualifying for "extended," thereby meeting the requirements for 99285. However, according to Medicare's '95 documentation guidelines, the case would be down-coded to level three, 99283.