The goal of coding is to uniformly describe clinical services. Developed in 1966, Current Procedural Terminology (CPT) is published and maintained by the American Medical Association (AMA). CPT is currently in its fourth edition and is updated annually by the AMA. The Healthcare Common Procedure Coding System (HCPCS) is the coding system utilized by Medicare and is based on a combination of CPT codes, regional and local payer codes. HCPCS codes are used by Medicare and monitored by the Centers for Medicare and Medicaid Services (CMS). These codes identify most of the tasks and services provided to a Medicare patient by medical practitioners, including medical, surgical, and diagnostic services. CPT is a listing of numeric codes and HCPCS contains both numeric and alpha-numeric codes.
Evaluation and management (E/M) services are a subset of codes contained in CPT/HCPCS and are published by the AMA in its annual CPT manual. E/M services are the most frequently billed emergency department (ED) services. When provided in the ED, these are identified with the ED Code levels 99281-99285 and 99291-92 of critical care. For purpose of coding, an ED is defined as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”1
The ED E/M codes do not differentiate between new or established patients or initial or subsequent visits, as in the office or inpatient setting. For coding purposes, the level of service is not affected if the patient has been previously seen in the ED. Emergency medicine codes 99281-99285 do not require time statements by the physician, unlike E/M levels for outpatient office/clinic and inpatient hospital visits.1
The content of emergency medicine service is divided into 3 key elements: history, physical examination, and medical decision-making (MDM) which will be discussed in greater detail later in the chapter.
The CPT/HCPCS codes selected for billing of provider services are entered into a billing form as required by the payer to whom services are being billed. Claim forms provide a uniform billing format that facilitates payer review and processing of the payment. Whether electronic or paper, claim forms must be completed accurately and signed electronically or personally by the provider. For every claim submitted, the provider assumes full responsibility for the accuracy of the information contained in the claim. It is critically important to ensure that all services are billed accurately.
The level of E/M services is determined by satisfying the listed code descriptor requirements for the key components of history, physical examination, and MDM. The number of key components required to assign an E/M level for emergency medicine requires all 3 key components to be satisfied. When the ED E/M codes are used, all 3 key components (history, physical examination, and MDM) must meet or exceed the requirements stated for each level of service. For example, 99284 ED ...