Billing: Difference between revisions
 
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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
===How to Support Higher MDM===
*Duration
*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===
*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>


===Past Medical, Family, Family, Social History===
===Physical Exam===
*Past Medical
*See [[Physical exam documentation]]
**Past Illnesses
*14 systems recognized by CMS<ref name="efficient"/>
**Major Injuries
**Surgical History
**Hospitalizations
**Immunizations
**Feeding/Dietary
*Family History
**Health Status
**Deaths
**Hereditary Diseases
*Social History
**Drug, etoh , tobacco
**Employment
**Marital Status
**Sexual History


==RVU For Level of Service<ref>http://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/</ref>==
==Critical Care Billing==
*99281 (Level 1) = 0.60 RVUs
*See [[Critical care documentation]] for detailed information
*99282 (Level 2) = 1.17 RVUs
*Critical care can be coded when total duration of critical care services ≥30 minutes
*99283 (Level 3) = 1.75 RVUs
*Time does not need to be continuous
*99284 (Level 4) = 3.32 RVUs
*Must exclude separately billable procedures from critical care time
*99285 (Level 5) = 4.90 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)]] = 6.31 RVUs 1st hr
**Critical Critical care can be coded when the total duration 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 pages}}


==References==
==References==

Latest revision as of 19:01, 25 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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