This article will define CPT Code 99284, explain the medical necessity to report CPT 99284, and the guidelines and clinical examples of CPT 99284. This article is about the 2022 version of this code. Be aware that this code was revised in 2023.
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 contract 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 several encounters with various patients over a long period.
It is often over-ambitious for doctors to estimate the time they spend face-to-face with each patient correctly.
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 plans.
It must also include a written order from the physician, which must be documented in their medical history.
Medical history and itemized 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 about the level of care billed is verified, and its suitability is evaluated.
Below are four billing examples of CPT code 99284.
Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.
Emergency department visit for an elderly female who has fallen and is now complaining of pain in her right hip and cannot walk.
Emergency department visit for a patient with flank pain and hematuria.
Emergency department visit for a female presenting with lower abdominal pain and a vaginal discharge.