Emergency Department Services: Coverage and Documentation Requirements


This Comparative Billing Report (CBR) focuses on physicians who submit claims for Emergency Department Services code family (CPT codes 99281-99285). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized Emergency Department Services code family (CPT codes 99281-99285) eCBR results log on to eServices.

Emergency Department Services code family (CPT codes 99281-99285): Coverage and Documentation Requirements 

CPT Code
Level of Severity
 Required Key Components
99281
Problem(s) are self-limited or minor.
  • A problem-focused history
  • A problem-focused examination 
  • Straightforward medical decision-making
99282
Problem(s) are of low to moderate severity.
  • An expanded problem-focused history
  • An expanded problem-focused examination
  • Medical decision-making of low complexity
99283
Problem(s) are of moderate severity.
  • An expanded problem-focused history
  • An expanded problem-focused examination 
  • Medical decision-making of moderate complexity
99284
Problem(s) are of high severity and require urgent evaluation
  • A detailed history
  • A detailed examination 
  • Medical decision-making of moderate complexity
99285
Problem(s) are of high severity and pose an immediate significant threat to life or physiologic function
  • A comprehensive history
  • A comprehensive examination 
  • Medical decision-making of high complexity

Education Resources
The Provider Outreach and Education (POE) team has published an article to address the issues pertinent to this CBR. Your practice is being advised to review the article entitled Errors in Emergency Department Services.

Methods
The metrics reviewed in this CBR are the proportion of billing for each CPT code in the grouping with comparisons done to peers with the same specialty in the state and the jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. For the purpose of this CBR, "peer group" is defined as other providers in Jurisdiction M (JM) who have the same specialty. The analysis shows the portions of your Emergency Department Services code family (CPT codes 99281-99285) claims at each level compared to your peers in JM.

Example of eCBR Results from eServices 

Example of eCBR Results from eServices

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.





Last Updated: 02/07/2018