Billing: Difference between revisions
(Major rewrite: updated for 2023 CMS guidelines, clean billing table, MDM as primary driver section, legacy requirements section, critical care billing, internal links, documentation pages template)
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==CMS Requirements for Billing==
==Background==
{| {{table}}
*Understanding ED billing is essential for appropriate reimbursement and documentation
| align="center" style="background:#f0f0f0;"|''' '''
*As of 2023, CMS E/M coding for ED visits is based primarily on '''medical decision making (MDM)''' or '''total time''', no longer requiring specific HPI/ROS/exam element counts for billing level<ref name="cms2023">American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>
| align="center" style="background:#f0f0f0;"|'''99281'''
*ED E/M visits use CPT codes 99281-99285; [[Critical care documentation|critical care]] uses 99291-99292
| align="center" style="background:#f0f0f0;"|'''99282'''
*Proper documentation directly impacts revenue and medicolegal protection
| align="center" style="background:#f0f0f0;"|'''99283'''
 
| align="center" style="background:#f0f0f0;"|'''99284'''
==ED E/M Billing Levels==
| align="center" style="background:#f0f0f0;"|'''99285'''
{|class="wikitable"
|-
|-
| ||Level1||Level 2||Level 3||Level 4||Level 5
! CPT Code !! Level !! MDM Complexity !! RVUs
|-
|-
| HPI||1 of 8||1 of 8||1 of 8||4 of 8||4 of 8
| 99281 || Level 1 || Straightforward || 0.64
|-
|-
| ROS||0||1||1||2||10
| 99282 || Level 2 || Low || 1.24
|-
|-
| PMHx, FamHx, Social Hx||0||0||0||1||2
| 99283 || Level 3 || Moderate || 2.10
|-
|-
| PE||1||2||2||5||8
| 99284 || Level 4 || Moderate || 3.57
|-
|-
| MDM||Straight‐forward||Low Complexity||Moderate Complexity||Moderate Complexity||High Complexity
| 99285 || Level 5 || High || 5.16
|-
|-
| 99291 || Critical Care (1st hr) || N/A || 8.19
|}
|}


===History of Present Present Illness Illness (HPI)===
==Medical Decision Making (MDM)==
*Location
*MDM is the '''primary driver''' of ED billing level under current CMS guidelines
*Severity
*MDM complexity is determined by three elements:
*Timing
**'''Number and complexity of problems addressed'''
*Modifying Factors
**'''Amount and complexity of data reviewed and analyzed''' (labs, imaging, records, discussions)
*Associated Associated Signs and Symptoms Symptoms
**'''Risk of complications, morbidity, or mortality''' from the patient's condition or management
*Onset
*Quality
*Duration


===Past Medical, Family, Family, Social History===
===How to Support Higher MDM===
*Past Medical
*Document '''differential diagnoses''' considered (see [[Differential diagnosis documentation]])
**Past Illnesses
*Document independent review of '''labs and imaging'''
**Major Injuries
*Note '''discussions with consultants''' and other providers
**Surgical History
*Document '''review of external records'''
**Hospitalizations
*Note '''prescription medications''' ordered
**Immunizations
*Document the '''risk assessment''' including potential complications
**Feeding/Dietary
*See [[MDM for different chief complaints]] for sample MDM documentation by chief complaint
*Family History
**Health Status
**Deaths
**Hereditary Diseases
*Social History
**Drug, etoh , tobacco
**Employment
**Marital Status
**Sexual History


===Review of Systems===
==Legacy CMS Requirements (Historical)==
There are 14 organ systems recognized by CMS:<ref>https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/</ref>
''Note: These element counts are no longer required for billing level under 2023 guidelines, but remain part of the medical record structure''
*Constitutional
*Eyes
*Ears, Nose, Mouth and Throat
*Cardiovascular
*Respiratory
*Gastrointestinal
*Musculoskeletal
*Integumentary (skin and/or breast)
*Neurologic
*Psychiatric
*Endocrine
*Hematologic/Lymphatic
*Allergic/Immunologic


===Physical Exam===
===History of Present Illness (HPI)===
CMS recognizes the following 14 systems as part of the physical exam:<ref>https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/</ref>
*Location, Severity, Timing, Modifying factors, Associated signs and symptoms, Onset, Quality, Duration
*Constitutional
*Eyes
*Ears, Nose, Mouth and Throat
*Neck
*Respiratory
*Cardiovascular
*Chest (Breasts)
*Gastrointestinal
*Genitourinary
*Lymphatic
*Musculoskeletal
*Skin
*Neurologic
*Psychiatric


===Medical Decision Making (MDM)===
===Past Medical, Family, Social History===
MDM complexity can be increased by documenting the following things as applicable
*Past medical/surgical history, Hospitalizations, Immunizations
*Discussing differentials
*Family history (health status, deaths, hereditary diseases)
*Review labs as it relates to the case
*Social history (drug/alcohol/tobacco use, employment, marital status)
*Independently review imaging
*Note discussions with consultants
*Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)
*Order prescription medications


'''CMS MDM example.'''
===Review of Systems===
*See [[Review of systems documentation]]
*14 organ systems recognized by CMS<ref name="efficient">https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/</ref>


Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.
===Physical Exam===
*See [[Physical exam documentation]]
*14 systems recognized by CMS<ref name="efficient"/>


==RVU For Level of Service<ref>CMS Clinical Fee Schedule for 2021 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched</ref>==
==Critical Care Billing==
*99281 (Level 1) = 0.64 RVUs
*See [[Critical care documentation]] for detailed information
*99282 (Level 2) = 1.24 RVUs
*Critical care can be coded when total duration of critical care services ≥30 minutes
*99283 (Level 3) = 2.10 RVUs
*Time does '''not''' need to be continuous
*99284 (Level 4) = 3.57 RVUs
*Must '''exclude''' separately billable procedures from critical care time
*99285 (Level 5) = 5.16 RVUs
*Can bill E/M '''plus''' critical care if the E/M is for the initial evaluation before the patient becomes critical
*[[Critical care documentation|99291 (Critical Care)]] = 8.19 RVUs 1st hr
**Critical Critical care can be coded when the total duration of time spent by a provider in providing critical care services to a critically ill or critically injured patient is at least 30 minutes, even if the time spent is not continuous.


==See Also==
==See Also==
*[[Documentation for emergency physicians]]
*[[Documentation for emergency physicians]]
*[[Critical care documentation]]
*[[MDM for different chief complaints]]
{{Documentation pages}}


==References==
==References==

Revision as of 11:05, 24 March 2026

Background

  • Understanding ED billing is essential for appropriate reimbursement and documentation
  • As of 2023, CMS E/M coding for ED visits is based primarily on medical decision making (MDM) or total time, no longer requiring specific HPI/ROS/exam element counts for billing level[1]
  • ED E/M visits use CPT codes 99281-99285; critical care uses 99291-99292
  • Proper documentation directly impacts revenue and medicolegal protection

ED E/M Billing Levels

CPT Code Level MDM Complexity RVUs
99281 Level 1 Straightforward 0.64
99282 Level 2 Low 1.24
99283 Level 3 Moderate 2.10
99284 Level 4 Moderate 3.57
99285 Level 5 High 5.16
99291 Critical Care (1st hr) N/A 8.19

Medical Decision Making (MDM)

  • MDM is the primary driver of ED billing level under current CMS guidelines
  • MDM complexity is determined by three elements:
    • Number and complexity of problems addressed
    • Amount and complexity of data reviewed and analyzed (labs, imaging, records, discussions)
    • Risk of complications, morbidity, or mortality from the patient's condition or management

How to Support Higher MDM

  • Document differential diagnoses considered (see Differential diagnosis documentation)
  • Document independent review of labs and imaging
  • Note discussions with consultants and other providers
  • Document review of external records
  • Note prescription medications ordered
  • Document the risk assessment including potential complications
  • See MDM for different chief complaints for sample MDM documentation by chief complaint

Legacy CMS Requirements (Historical)

Note: These element counts are no longer required for billing level under 2023 guidelines, but remain part of the medical record structure

History of Present Illness (HPI)

  • Location, Severity, Timing, Modifying factors, Associated signs and symptoms, Onset, Quality, Duration

Past Medical, Family, Social History

  • Past medical/surgical history, Hospitalizations, Immunizations
  • Family history (health status, deaths, hereditary diseases)
  • Social history (drug/alcohol/tobacco use, employment, marital status)

Review of Systems

Physical Exam

Critical Care Billing

  • See Critical care documentation for detailed information
  • Critical care can be coded when total duration of critical care services ≥30 minutes
  • Time does not need to be continuous
  • Must exclude separately billable procedures from critical care time
  • Can bill E/M plus critical care if the E/M is for the initial evaluation before the patient becomes critical

See Also

Documentation Pages

References

  1. ↑ American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.
  2. ↑ 2.0 2.1 https://efficientmd.com/a-simplified-explanation-of-emergency-department-e-m-coding/
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