Pain Management Coding Alert

Question:  Our PM specialist was called to the ED to see an established patient for an evaluation and management (E/M) service. Notes indicate that the provider performed a detailed history, a detailed exam, and moderate-com­plexity medical decision making (MDM). I’ve never used ED E/Ms before, so can you help me choose the correct one for this patient?

Tennessee Subscriber

Answer: On your claim, you should report 99284 (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 …) for the PM specialist’s service.

Since your provider might call upon you again to code for ED E/Ms in the future, here’s a little info on how these codes differ from office E/M service codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …).

No new, established: As you can see from the descriptor for 99284, ED E/M codes do not distinguish between “new” and “established.” This is because no matter how many times a patient reports to an ED, he is still considered new by the facility and thus must be treated as a new patient each time he reports to the ED.

3-component checklist: Being that each patient is considered new each time he reports to the ED, you’ll have to satisfy all three components of the ED E/M service for each visit; for established patient E/Ms 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal …) through 99215, you only need to fulfill two of the three components for each E/M level.

No time component: As you’ll notice, there are no time estimates for ED E/M 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 …) through 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 …). So when you choose an ED E/M, the amount of time spent on any or all portions of the services is irrelevant; all that matters with 99281-99285 is level of history, examination, and medical decision making (MDM).

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