Emergency Room CPT Coding: An Overview
Some of the most used CPT codes in the Emergency Department (“ED”) setting are the Evaluation and Management (“E/M”) code set (99281-99285). Emergency Medicine providers treat a wide array of patients resulting in a range of E/M services. Historical trends may provide a signal to identify which providers to review, and coding changes offer reviewers the latest guidance for assessing appropriate code level use.
CPT defines an ED as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention.” The American College of Emergency Physicians (ACEP) lists all five levels of ED E/M services among its top 20 most common ED reimbursement codes.
The ED E/M codes are used to report the level of care provided to a patient during their visit to the ER. The level of care is determined by factors such as the complexity of the patient’s medical history, the extent of the examination, and the medical decision-making involved in their care.
E/M Changes
With the changes implemented in the E/M space, it is important to understand previous trends with ED E/M codes for potential comparison of utilization going forward. Since 2023, there was a change in the E/M guidelines. More specifically, these changes differ from the 1995 E/M guidelines in several ways.
- Elimination of history and physical exam as elements for code selection
- E/M code selection is based on medical decision making or total time
- Modifications to the criteria for determining the level of medical decision making (“MDM”)
The scoring methodology for ED E/M levels was updated to reflect a more clinical approach. In this approach, the importance of MDM is emphasized. The updated components of MDM include the number and complexity of problems addressed (“COPA”), amount and/or complexity of data to be reviewed, and risk of morbidity or mortality of patient management. According to CPT, risk is defined based on the “usual behavior and thought process” of a provider in the same specialty.
Guidance on measuring COPA and MDM can be found on the ACEP website, which offers the 2023 Emergency Department Evaluation and Management Guidelines.
Past ED E/M Coding Trend
The study, “Trends in Emergency Department Exam Medicare Reimbursements Between 2010 to 2018”, outlines a perspective of previous coding guidance and utilization, which for some plans and lines of business can be a viable measurement and comparison for trending. According to the study, there was an increase in the charges submitted by emergency physicians for ED E/M services, but a decrease in the payments from Medicare as a percentage of the submitted charges. The utilization of level five (5) ED E/M examinations increased 22.3% from 2010 to 2018, while the utilization of the others decreased.
How Fraud Scope Can Assist
Fraud Scope can assist in identifying outlier utilization or volumes of services trending on the higher level of services. Codoxo’s proprietary AI can assist in identifying signals through pattern-based detection models, such as Outlier Abuse, Suspicious Trends, Time Behavior or Upcoding:
- Providers utilizing high level ED E/M services compared to their peers.
- Recent or increasing trends for ED E/M utilization during time periods.
- Possible upcoding of ED E/M services when compared to peers.
References:
2023 Emergency Department Evaluation and Management Guidelines – ACEP, https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs/
MDM Determination in the ED – AAPC Knowledge Center, https://www.aapc.com/blog/90815-mdm-determination-in-the-ed/
Trends in Emergency Department Exam Medicare Reimbursements [2010 to 2018]
Ghaith S, Ginsberg Z, Pollock J, et al. (July 17, 2024) Trends in Emergency Department Exam Medicare Reimbursements Between 2010 and 2018. Cureus 16(7): e64755. doi:10.7759/cureus.64755