As the practice of emergency medicine has changed and expanded over the years, so has the complexity of coding for the various types of emergency department visits. When the 1992 CPT E/M code set for emergency medicine was developed, patients received limited workups in the emergency department and were admitted as inpatients for their evaluations. Today, much of the evaluation and investigation which was previously performed as an inpatient is now being done routinely in emergency departments. For example, a patient with cirrhosis who presents with severe abdominal ascites may now have a paracentesis performed in the emergency department using ultrasound guidance which may obviate the need for admission. The increase in intensity of service has caused a shift to the right in the evaluation and management distribution curve. Many patients now received advanced critical care in the emergency department for conditions such as STEMI’s and CVA’s. In addition, when there is diagnostic uncertainty many emergency physicians now perform extended evaluations, treatments and serial examinations which is the definition of observation care. Below is a partial listing of some of the CPT codes commonly used by emergency physicians.
1. Emergency Department Evaluation & Management (E/M) Codes (99281-99285)
This code set was developed in 1992 for use by emergency medicine physicians. Five (5) different levels of service are used depending on the nature of the presenting complaint to reflect the amount of history obtained, exam performed, diagnostic testing required and complexity of medical decision making. It is important to note that the emergency department code set does not have typical times assigned, in recognition of the multitasking performed by emergency physicians.
2. Observation Codes (99217-36)
Emergency physicians now routinely provide more intensive services than when the original emergency services codes were developed. Observation codes can be used whenever there is diagnostic uncertainty requiring extended evaluations, treatments and serial examinations to determine whether a patient requires admission or can be safely discharged home. For example, a patient with chest pain at risk for ACS may be monitored in the ED for several hours and receive serial EKG’s and cardiac troponins to determine if admission is required. Observation is defined by the service provided, not the area of the hospital a patient is located in. In other words, a patient does not need to be admitted to an observation unit for the emergency physician to provide observation care. Some examples of patients who may require continued evaluation and treatment beyond the usual emergency department length of stay include patients with chest pain, asthma, abdominal pain, renal calculi, dehydration, or drug ingestion/overdose. Please see the Observation for Physicians FAQ for more information about billing observation care.
3. Critical Care Codes (99291-92)
Emergency physicians provide a wide range of services and are not restricted to using just the emergency department services codes. Whenever a patient is critically ill and the emergency physician provides critical care, the critical care codes should be reported. Note, critical care services are time based meaning the physician must specify the total amount of time spent providing critical care services to the patient. See the FAQ on Critical Care for more information about billing critical care.
4. Procedure Codes
Emergency room physicians commonly performed procedures such as laceration repair, intubation, central lines, lumbar punctures, or paracentesis. Emergency physicians also provide a wide range of orthopedic care treating fractures and dislocations. Be sure to document any procedures you perform because most procedures have a distinct CPT code which should be reported in addition to any separately identifiable evaluation and management service provided.
5. EKG Billing
Emergency physicians routinely review and interpret EKGs and use that information when making clinical decisions. Your review and interpretation of an EKG should be documented to accurately reflect the complexity of medical decision making. If certain criteria are met, emergency physicians may bill for the interpretation of the EKG. Please see the X-ray/EKG FAQ for more information about billing EKG’s.
6. Radiology & Ultrasound Billing
Emergency physicians routinely review x-rays and use this information when making clinical decisions. Your review and interpretation of x-rays should be documented to help reflect the complexity of medical decision making. If certain criteria are met, emergency physicians may also bill for the interpretation of x-rays. Please see the X-ray/EKG FAQ for more information about billing for x-rays.
Bedside ultrasound has proven to be a tremendous tool in emergency medicine and has gained widespread use. If certain criteria are met, and the ultrasound interpretation is documented, emergency physicians may bill for ultrasounds. Please see the Ultrasound FAQ for more information about billing for ultrasounds and which codes to report.
Updated April 2023
The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.
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For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director, at (469) 499-0133 or email@example.com.