cpt 99284

(2022) CPT Code 99284 – Description, Guidelines & Clinical Examples

This article will define CPT Code 99284, explain the medical necessity to report CPT 99284, the guidelines and clinical examples of CPT 99284.

CPT Code 99284 Description

CPT Code 99284 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99284):

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:

Component 1: A detailed history

Component 2: A detailed examination

Component 3: Medical decision making of moderate complexity

Counselling 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 require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.

No contrast is made between new and established Emergency Department (ED) patients. Evaluation and management (E / M) services in the ER category can be noted for any new or established patient presenting for treatment in the ER.

Time is also not a detailed component for E / M service levels in the ED because emergency room services are generally provided at varying intensity, often including a number of encounters with various patients over a long period of time.

It is often over ambitious for doctors to correctly estimate the time they spend face-to-face with each patient.

CPT 99284 BCBS Guidelines

Documentation of the patient’s medical history for emergency room (ED) diagnosis and treatment must include current symptoms, diagnoses, and treatment plan.

It must also include a written order from the physician, which must be clearly documented in their medical history.

Medical history and itemised bills may be requested from the provider to assist in the level of care provided.

Medical history and records are used to define the scope of the medical history, the scope of the examination performed, the complexity of medical decision making (number of diagnoses or treatment options, quantity and / or complexity of the data to be reviewed, and risk of complications), and / or morbidity or mortality) and services provided.

This information is verified in relation to the level of care billed and its suitability is evaluated.

CPT Code 99284 Examples

Example 1

Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.  

Example 2

Emergency department visit for an elderly female who has fallen and is now complaining of pain in her right hip and is unable to walk. 

Example 3

Emergency department visit for a patient with flank pain and hematuria. 

Example 4

Emergency department visit for a female presenting with lower abdominal pain and a vaginal discharge. 

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