Billing

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
• 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

• See Review of systems documentation
• 14 organ systems recognized by CMS

Physical Exam

• See Physical exam documentation
• 14 systems recognized by CMS

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

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations