“My group takes “call” at our local hospital, and this necessitates seeing patients in the emergency room (ER) on occasion. We are not all in agreement regarding what E/M codes should be used in this scenario. We have come up with different encounters:
1. A patient seen in the ER. The patient is then discharged to follow up for outpatient care.
2. A patient is seen in the ER and then admitted for continued medical treatment.
3. A patient is seen in the ER and is taken straight to the operating room for surgical treatment.
What E/M code series would you recommend using for these different scenarios? Thank you for the help!”
When a patient is seen in the emergency room (ER) or in the emergency department of a hospital, it is important to know the rules that need to be followed regarding the billing of E/M codes:
- • Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
- • Emergency department classification of new versus established patient: No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
Of course, it is important to know and understand the E/M codes for services rendered in the emergency room or the emergency department of a hospital. The level of E/M service is based upon a medically appropriate history and/or a medically appropriate examination and medical decision making. As stated above, time is not a component for the emergency department levels of E/M services.
- • CPT 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
- • CPT 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
- • CPT 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
- • CPT 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
- • CPT 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
Issue #1: A patient seen in the ER. The patient is then discharged to follow up for outpatient care.
In this scenario the appropriate level of E/M service that was performed in the emergency department is the appropriate E/M code to bill.
Issue #2: A patient is seen in the ER and then admitted for continued medical treatment.
Per the CPT Manual, when a patient is admitted to the hospital as an inpatient during an encounter in another site of service (eg. hospital emergency department, observation status in a hospital, office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered to be part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.
Issue #3: A patient is seen in the ER and emergently taken straight to the operating room for surgical treatment. In this scenario the appropriate level of E/M service that was performed in the emergency department is the appropriate E/M code to bill. Of course, since the patient is having surgery performed, the 57 modifier would need to be appended to the E/M service to indicate “Decision for Surgery.”
This is my opinion.
Michael G. Warshaw
DPM, CPC
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