cpt code 99285

(2022) CPT Code 99285 Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code 99285 is an Emergency Department (ED) code that is typically reported daily and does not differentiate between new or established patients. This article will help you with proper coding, billing guidelines, modifiers, and reimbursement for CPT 99285.

CPT Code 99285 Description 

There are five levels under the emergency department services category represented by 99281-99285. All decks require the three key components (history, exam, and medical decision-making [MDM]) to be documented.

CPT code 99285 is the uppermost level of this series.

99285 CPT code ED visit for the Evaluation and management of a patient, which requires these three components within the limitation imposed by the urgency of the patient’s clinical condition and mental status:

  1. A comprehensive history
  2. A comprehensive examination
  3. Medical decision-making of high level.

All three components mentioned above must be met or exceeded for the level of service selected. Time is not a factor when selecting this E/M Service. An ED is typically an organized facility available 24 hours a day, providing unscheduled services to patients needing urgent medical attention.

Counseling & conciliation of care with other physicians, other health professionals, or agencies are provided consistent with the nature of the problem. The patient’s or family’s needs are also included. Usually, the reporting problems are of high severity and pose an immediate significant threat to life or physiologic function. 

CPT code 99285 is used to report emergency department services for new or established patients. 

99285 cpt code

CPT Code 99285 Coding Tips

Report place of service (POS) code 23 for services provided in the hospital emergency room.

Medicare has provisionally identified these codes as telehealth/telemedicine services.

Current Medicare coverage guidelines, including place of service, should be checked.

For coverage guidelines, commercial payers should be contacted.

Only the medically necessary portion of the Emergency Department visit is allowed by Medicare. 

Though if a complete note is generated at the time of the visit, only the necessary services for the patient’s condition can be considered in determining the level of an E/M code. Medical necessity must be clearly stated and support the level of service reported.

Medical necessity is the Diagnosis code reported to tell the payer why service is performed. For a service to be considered medically necessary, diagnosing or treating a patient’s medical condition must be reasonable and necessary.

When selecting the E/M code 99281 – CPT code 99285, comorbidities and other underlying health conditions in and of themselves are not considered Until unless their presence significantly increases the complexity of the medical decision-making.

The time spent only face to face with the Physician is considered in selecting an E&M level performed in the emergency department. The time spent by other staff, including nurses, practitioners, etc., is NOT considered in choosing the appropriate level of service.

CPT Code 99285 Billing Guidelines

The level of E&M service billed must be based on the treatments performed concerning the medical care required by the reported symptoms and resulting in the patient’s diagnosis. Professional codes are based on complexity and accomplished work, including the “cognitive” effort. 

Only one unit of CPT code 99285 is allowed to bill on the same day.

E&M CPT code 99285 is not reimbursable more than once to the same provider.

The Cost and total RVUs of 99285 CPT code are $178.91 and 5.17000 respectively for both National and Global Facility and Non-Facility Services.

Facility codes reflect the volume and ferocity of resources used by the facility to provide care.

While billing, Claims should be submitted with supportive Documents when requested by the provider to support the level of care rendered. The documentation must identify and support ED E/M codes billed. The documents that support it must be included in the appeal request if a denial is appealed.

CPT Code 99285

Three critical components within the limitations imposed by the necessity and urgency of the patient’s clinical condition and mental status are given below for the Evaluation and management of a patient in the Emergency department:

  • Detailed history
  • Detailed exam
  • MDI (Medical decision making) of severe complexity
  • Reason for encounter
  • Problem relevant ROS (Review of systems)
  • Extended HPI – An extended HPI consists of four or more elements of the HPI. The medical records should include all aspects.

Review of Systems

ROS directly related to the identified condition.

Medically necessarily review of all body systems history.

Complete past, social, and family history.

History of Present Illness

A Sequential description of the development of the patient’s present illness from the first sign or the initial encounter to the present. Descriptions of current condition may include:

Location, Quality, Severity of illness,

Timing: which time does it worsen/alleviate,

Context and Modifying factors,

Relative signs or symptoms to the presenting problem.

Chief Complaint

The Chief Complaint is a brief statement from the patient describing specific symptoms, condition, problem, diagnosis, and Physician recommended return or other factors that are the primary purpose of the patient’s admission.

Review of Systems

A review of systems is usually done by asking a series of questions from the patient and identifying physical signs and symptoms to rule out the illness.

ROS, the Following systems are reviewed:

Constitutional (fever, weight loss, etc.), Eyes, Ears, Nose, Mouth, Throat, Cardiovascular, Allergic/Immunologic Respiratory, Musculoskeletal, Integumentary (skin and breast), Gastrointestinal, Neurologic, Psychiatric, Endocrine, Genitourinary, and Hematologic/Lymphatic.

Past, Family, and Social History (PFSH)

It consists of a review of the following:

Patient’s past illnesses, surgeries, injuries, and treatments.

Family History: medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk.

Social History: an age-appropriate present and past ADLs (Activities of Daily living).

Practitioner/Clinician choosing to use time as the determining factor:

  1. Document time in the patient’s medical record.
  2. The documentation should have to support sufficient detail about the nature of the counseling.
  3. Code selection should be based on the total time of the encounter. The medical record should be documented in sufficient detail to justify the code selection.

CPT Code 99285 Reimbursement

Reimbursement and payment determination are subject to, but not limited to:

Group or Individual benefit,

Provider Participation Agreement,

Mutually exclusive logic and medical necessity,

Mandated or legislatively required criteria will always be supplanted.

Medicare Providers are responsible for confirming and ensuring that visits are coded accurately. A Distinct provider number is used when a service is billed to ensure that the provider has reviewed and verified the accuracy of everything on the submitted claim.

The patient’s condition to ensure claims submitted with the correct level of service should be documented clearly

In some cases where the provider participates, co-payment, coinsurance, and deductible should be applied based on member benefits.

CPT Code 99285 Modifiers With Examples

Modifiers provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Modifiers that are applicable with CPT code 99285 are given below:

  • 24, 25, 27, 57, 99, AI, AQ AR, CC, CR, CS, ET, EY, FR, FS, G0, GA, GC, GJ, GK, GQ, GR, GT, GU, GY, GZ, KX, Q5, Q6, QJ, TH.

Modifiers often used in medical coding for CPT code 99285 are 24, 25, and 57.

Below are the descriptions and usage of these modifiers.

Modifier 24 With Example

Unrelated E&M service given by the Same Physician or Other Qualified Health Care Professional During a global period (postoperative) of an effective procedure.

Modifier 24 is appended with the E&M code when a patient is in the global fee period of a major or minor procedure performed within the global fee period. Still, They returned for a different condition or procedure with another Diagnosis code.

Example:

If a patient had total hip arthroplasty one month ago, he comes again for Evaluation and management of abdominal pain. So modifier 24 should be appended to 99285 CPT code to distinguish it as an unrelated E&M service. A patient would not be counted as a part of the global fee period.

Modifier 25 With Example

Separate identifiable E&M service performed by the Same Physician or Other Qualified Health Care Professional on the Same Day when another minor or major procedure is performed.

Use modifier 25 always when the Evaluation and management service is Distinct, significantly identifiable, and separately documented as another service different from the E&M service.

Use modifier 25 on an E/M service performed during the same session as a preventive care visit when significant, separately identifiable E/M service is rendered in addition to the preventive care. ICD 10 (Diagnosis) Code should identify the service as non-preventive.

Example:

A patient comes to the ED for severe knee pain, and the doctor performs arthrocentesis of the knee joint. In this case, modifier 25 would be appended to the CPT code 99285, describing the arthrocentesis as a different procedure.

Modifier 57 With Example

57- “Decision for surgery.” An E&M service resulted in the decision to perform the significant/major surgery identified by using a 57-modifier to the appropriate level of E/M service.

Use Modifier 57 to indicate an Evaluation and Management (E/M) service when the initial decision to perform surgery is the day before major surgery (90 days global) or the day of major surgery.

Example:

A patient came to the ED after having a Road traffic accident. He fractured his lower leg. The doctor decides to do significant surgery ORIF (Open reduction Internal fixation). So, in this case, modifier 57 would be appended to CPT code 99285.

CPT Code 99285 Examples

The following is a list of examples of when the 99285 CPT code may be billed.

Example 1

Emergency department visit for a patient with a complicated overdoes requiring aggressive management to prevent side effects from the ingested materials.  

Example 2

Emergency department visit for a patient with a new onset of rapid heart rate requiring IV drugs. 

Example 3

Emergency department visit for a patient exhibiting active, upper gastrointestinal bleeding.

Example 4

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. 

Example 5

Emergency department visit for a patient with an acute onset of chest pain compatible with symptoms of cardiac ischemia and/or pulmonary embolus. 

Example 6

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.  

Example 7

Emergency department visit for a patient with a new onset of a cerebral vascular accident.  

Example 8

Emergency department visit for acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness. 

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