This article will define CPT Code 99285, explain the medical necessity to report CPT 99285, the guidelines and clinical examples of CPT 99285.
CPT Code 99285 Description
CPT Code 99285 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99285):
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status:
CPT 99285 Component 1: A comprehensive examination
1. General, multisystem exam OR complete exam of a single organ system.
2. Body areas recognized:
- Genitalia/groin and buttocks
- Each extremity
- Chest/including breasts and axilla
- Head/including face
3. Organ systems recognized:
- Eyes, ears, nose,
- mouth, throat
CPT 99285 Component 2: Comprehensive history
- Review of systems directly related to the problem(s) identified in the HPI
- Problem pertinent review of systems
- Reason for admission
- Medically necessary review of ALL body systems’ history
- Medically necessary complete past, family, and social history
- Extended history of present illness (HPI). Includes 4 or more elements of the HPI or the status of at least three chronic or inactive conditions
CPT 99285 Component 2: Medical decision making of high complexity.
This refers to the complexity of establishing a diagnosis and/or selecting a management option.
Medical Necessity Of CPT 99285
Medicare allows only the necessary portion of a face-to-face visit. A complete note will be drawn up of all necessary services and conditions for the patient at the time of the visit and will be taken into account in determining the level of medical need for services
CPT 99285 Examples
Emergency department visit for a patient with a complicated overdoes requiring aggressive management to prevent side effects from the ingested materials.
Emergency department visit for a patient with a new onset of rapid heart rate requiring IV drugs.
Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.
Emergency department visit for a previously healthy young adult patient who is injured in an automobile accident and is brought to the emergency department immobilized and has symptom compatible with intra-abdominal injuries or multiple extremity injuries.
Emergency department visit for a patient with an acute onset of chest pain compatible with symptoms of cardiac ischemia and/or pulmonary embolus.
Emergency department visit for a patient who presents with a sudden onset of ‘’the worst headache or her life,” and complains of a stiff neck, nausea, and inability to concentrate.
Emergency department visit for a patient with a new onset of a cerebral vascular accident.
Emergency department visit for acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness.