In recent years there has been a change in how some emergency care services are delivered. There continue to be hospital-based emergency departments with typical ground and air ambulances delivering patients with serious illnesses including myocardial infarction, traumatic injury and stroke. At the same time we have seen an increase in free-standing emergency room facilities.

The American Medical Association Access to Emergency Services Policy H-130.970 recognizes the following:

“(A) Emergency services should be defined as those health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily function; or (3) serious dysfunction of any bodily organ or part.”[1]

Since the onset of the COVID-19 period there has been a trend of increasing use of complex emergency department (ED) evaluation and management (E&M) procedure coding, with diagnosis codes that do not immediately indicate an emergency department level of care might be needed.

The American Medical Association (AMA) Current Procedural Terminology (CPT) has five levels of ED E&M services, defined by the five CPT codes in the range 99281-99285.[2] Each level of ED E&M service requires all three key components of history, examination and medical decision-making (MDM) to “meet or exceed the stated requirements” for the level of service reported.[3]

AMA CPT code descriptions for these ED E&M codes include a statement about the patient’s presenting problem. For the two highest level codes the presenting problems are usually of high severity:

  • CPT code 99284 description states, “Usually the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.”
  • CPT code 99285 description states, “Usually the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.”

Recent trends reflect increased use of complex ED E&M procedure codes (99284-99285), billed with or without CPT modifier CS (Cost sharing waiver), and with possible COVID-19 related diagnosis codes, including:

  • Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out)
  • Z11.59 Encounter for screening for other viral diseases
  • Z20.828 Contact with and (suspected) exposure to other viral communicable diseases

As detailed above, the use of Emergency Department E&M procedure codes typically require services beyond COVID-19 screening and lab testing (which may be performed by a separate lab provider).

Potential schemes

  • Use of only COVID-19-related screening or exposure-to diagnosis codes and billed with complex ED E&M procedures (99284-99285).
  • Use of complex ED E&M codes (99284-99285), with screening or exposure-to diagnoses, when there are no other lab or diagnostic tests.
  • Excessive complex E&Ms per day emergency room, with COVID-19 related diagnosis codes, may be an indicator of upcoded E&Ms and/or billing for services not rendered. This is especially applicable when the provider performs “drive-thru” COVID-19 testing billed with complex ED E&Ms.
  • Complex ED E&M procedures billed for the same patient, with COVID-19 related diagnosis codes, for multiple dates of service.
  • Complex ED E&M procedures, with COVID-19 related diagnosis codes, billed for multiple members of the same family on the same date of service.

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