ED Coding and Reimbursement Alert

Question: Why is the medical decision-making level the same for 99283 and 99284?

Cathee Helton
Emergency Physicians of Poplar Bluff, Mo.

Answer: Lamon Willis, CPC, a coding consultant with St. Anthonys Consulting Group in Jacksonville, Fla., who specifically codes for emergency room physicians, addresses these questions by stating that the medical decision-making for emergency department evaluation and management (E/M) codes 99283 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem-focused history and examination, and medical decision-making of moderate complexity) and 99284 (emergency department visit for the evaluation and management of a patient, which requires a detailed history and examination, and medical decision-making of moderate complexity) may seem to be identical but actually can be very different.

Both 99283 and 99284 have decision-making of moderate complexity. The presenting problem, however, is what shows a clear distinction between the two.

For the 99284 level of service (LOS) the CPT guidelines state: 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. Also in CPT clinical examples, you will see some clear differences between the 99283 and 99284 LOS.

Because a moderate level of medical decision-making is found in both the 99283 and 99284 LOS, some emergencyphysician billing companies have come up with a way of determining differences to make clear distinctions between the two. They have tagged these low moderate for the 99283 and high moderate for the 99284 LOS.

For example, prescription-drug management would be used in the low moderate, while IV with additives would be used in the high moderate. These are just a couple of examples of what some are doing to make distinctions. It should be noted that these ideas and uses of low and high moderate LOS are not recognized and/or ok for use as deemed correct by HCFA or the AMA. Neither organization has said these ideas are incorrect or wrong for use either.

For these reasons, the agencies that be are working in developing new E/M guidelines for a more clear and precise determination of coding for services. Hopefully, those new guidelines will be forthcoming after trials in California.