(2023) CPT Code 99283 | Description, Guidelines, Reimbursement, Modifiers & Examples
CPT code 99283 bills for services performed by the physician in the emergency department (ED). ED visits do not differentiate between new and established patients and reports per day. ED visits bills with five category CPT codes (99281-99285).
Summary
CPT codes 99281-99285 require three key components of evaluation and management CPT codes such as history, exam, and medical decision making (MDM).
The lowest CPT code is 99281, including problem-focused history and exam and straightforward MDM.
CPT 99282 and CPT code 99283 describe an expanded problem-focused history and exam with MDM of low or moderate complexity, respectively, represented by 99282 and 99283.
The encounter typically addresses common to reasonable severity health concerns at these service levels.
The last two levels of service in this category represent high-severity problems.
Code 99284 describes a high-severity health concern that does not pose an immediate threat to life or physiologic function; a detailed history and exam in conjunction with moderate complexity MDM needs for reporting this level of service.
The highest level of service, 99285, requires a comprehensive history and examination with high complexity MDM for high-severity health issues that pose an immediate threat to the life or physiologic function of the patient.
Time does not write as a descriptor for these CPT codes (99281-99285) due to the complex nature of the patient’s condition, and the physician sees multiple patients simultaneously.
However, it is unable to determine face-to-face time accurately.
CPT Code 99283 Description
CPT code 99283 reports by the physician; or other qualified health professionals when service renders at the emergency department for the evaluation and management of a patient.
It typically requires 3 out of 3 key components:
- An expanded problem-focused history
- An expanded problem-focused examination
- Medical decision-making of moderate complexity
The nature of presenting the problem must reflect the patient’s current condition and or family needs.
CPT Code 99283 Reimbursement
A maximum of one unit of CPT code 99283 is allowed to bill on the same day.
In contrast, a maximum of three times are allowed when documentation supports the medical necessity of CPT code 99283.
The CPT 99283 cost and RUVS are as follows when performed in the facility, it will be $76.16 and 2.20081, respectively.
In contrast, non-facility will be $76.16 and 2.20081, respectively.
Telehealth services are provided to patients most frequently due to COVID 19 situation.
In this case, it is appropriate to attach modifier 95 with CPT code 99283.
If it performs at the hospital due to some emergency, then it will be billed Q3014 for reporting telehealth services provided at the hospital.
CPT Code 99283 Modifiers
The most frequent modifiers used with 99283 CPT code are 24, 25, 57, and 95.
Modifier 25 will be appended with 99283 CPT code when it performs in conjunction with other services that are not allowed to be billed together on the same day.
For instance, the physician saw the patient with a headache and had shoulder surgery on the same day by the same physician.
In contrast, modifier 24 will be attached to CPT code 99283 when performed in the postoperative period with unrelated procedures or services.
Modifier 95 will be attached to 99283 CPT code if the service visits as a telehealth visit.
Modifier 57 will be attached to CPT 99283 if the physician plans to do surgery the same day the E/M visit performs.
CPT Code 99283 | Billing Guidelines
Documentation supports the medical necessity of service and should be medically appropriate to reflect the patient’s current condition.
CPT 99283 reports with the place of service 23 for a hospital emergency room.
Q3014 is applicable when the hospital provides telemedicine service as an origin site to other outpatient hospital patients.
CPT code 99283 requires 3 out of 3 key components (history, exam, and medical decision making) to meet the criteria or exceed the level of service, which are as follows:
Detailed history: It requires at least 4 HPI elements, 10 ROS systems, and one history component is needed 2 out of 3 components (PFSH).
Detailed Exam: It requires eight-plus systems as per 95 documentation, and nine-plus systems with two-plus bullets require 97 documentation.
High MDM: It requires at least 2 out of three components of MDM that must be met on that basis of risk, diagnostic or treatment, Data management services like Medicine, Laboratory, review, counseling, Interpretation of services.
If time is mentioned in the medical notes, it is appropriate to bill based on time instead of MDM, typically requiring 35 minutes on the patient’s hospital floor or unit.
Critical care services (99291-99292) are not allowed to be billed together in conjunction with ED code (CPT 99283).
CPT code 99283 cannot be billed together on the same date in combination with Observation services (99217-99220, 99234-99236)
99283 CPT code has no time limitations because it is difficult to determine the time during multiple encounters with patients simultaneously in ED.
In addition, ED care does not differentiate between new and established patients.
CPT Code 99283 Examples
The following are examples of CPT 99283 when this service will be billed:
Example 1
58 y/o male with a PMH of HTN, HLD, hypothyroidism presenting to the hospital outpatient setting because of a headache and high blood pressure before arrival.
The patient lays down in bed at 10 pm and begins having a gradual onset pulsating frontal and occipital headache.
He reports that the pain was very severe. His headaches are usually associated with HTN.
The blood pressure shows a value of 210/100 and denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting.
The physician ordered a series of diagnostic tests CT, MRI, and EKG.
EKG was independently interpreted and reviewed by the doctor. Patient reports improvement in HA with Tylenol.
Example 2
A 51-year-old-female presents to the emergency with syncope. The patient applies a nicotine patch earlier.
The patient had a brief episode of feeling hot, numbness, and tingliness in her b/l hands, “gas discomfort” in her stomach, headache.
When she tried to get up, she lost consciousness(witnessed by her partner, who I spoke to for more history).
Partner states she was only out for a few seconds before perking up to routine.
Pt states she has had episodes like this in the past but several years ago. No known cardiac history.
Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, Zofran.
EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions.
CXR: My interpretation showed no acute abnormalities.
Example 3
36-year-old male presents to the emergency department with PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, and gout presenting to the Office today for dark blood stools for two days.
He states that he started having diarrhea yesterday and has had 4 BM in the past two days.
The patient denies nausea, vomiting, CP, SOB, dizziness, fevers, chills, took eliquis this morning.
The physician also notes worsening bilateral lower extremity edema for which he takes Lasix.
He took Indomethacin for four days for a presumed gout flare. The colonoscopy was done three years ago, found benign polyp but otherwise WNL.
Physician plan to admit and Plan Labs, EKG, CT abdomen, and Pelvis, and prescribed Medicine.
Example 4
70-year-old female presents to ED with a history of HLD presenting to the OPD for substernal chest pain.
The patient worked out daily, was a very healthy, active senior, lived at home, and worked out today.
After the workout, she took a sip of water, and she had substernal chest pain, none radiating, associated with weakness.
However, Gatorate helped with the substernal chest pain. She had no chest pain shortly after.
However, her trainer told her to see a provider. She went to urgent care with asymptomatic resolved chest pain; they sent her over here because she had a family history of MI in her family.
Her brother died of MI at age 48 EKG without ischemic changes. Low suspicion for ACS. HEART score 3.
Example 5
38-year-old female past medical history of chronic gastritis diagnosed on endoscopic two weeks ago presenting with one month of on and off palpitations and lightheadedness.
The patient states that she has been feeling off for the last month and describes her symptoms as when she wakes up in the morning and feels fogginess has bouts of palpitations with associated lightheadedness without syncope.
The patient cannot pinpoint a trigger and states her symptoms resolve independently.
Palpitations last anywhere from seconds to minutes.
The patient endorses that she has a healthy diet and does not do any narcotics drink alcohol or smoke.
The patient otherwise denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation.
The physician decided will obtain EKG labs chest x-ray reassess.
EKG normal sinus rhythm at 74 bpm with a QTC of 426 no ST elevations or depressions.
Example 6
Emergency department visit for a sexually active female complaining of vaginal discharge who is afebrile and denies experiencing abdominal or back pain.
Example 7
Emergency department visit for a well-appearing 8-year-old who has a fever, diarrhoea, and abdominal cramps; is tolerating oral fluids and is not vomiting.
Example 8
Emergency department visit for a patient with an inversion ankle injury, who is unable to bear weight on the injured foot and ankle.
Example 9
Emergency department visit for a patient who has a complaint of acute pain associated with a suspected foreign body in the painful eye.
Example 10
Emergency department visit for a healthy for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness, or memory deficit.
