Emergency Department Evaluation and Management Services

Published 04/10/2019

This electronic Comparative Billing Report (eCBR) focuses on providers who have submitted claims for Emergency Department Evaluation and Management (E/M) services (CPT codes 99281-99285). eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on Emergency Department E/M Services (CPT codes 99281-99285), log into our eServices portal. An eCBR will be available for providers who have at least 10 claims in history for this CPT code family during the time period selected.

Overview of CPT codes 99281-99285

CPT Code
Description
Documentation Requirements; All three elements are required
99281
Problem(s) are usually self-limited or minor
  • A problem-focused history
  • A problem-focused examination
  • Straightforward medical decision-making
99282
Problem(s) are usually 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 usually of moderate severity
  • An expanded problem-focused history
  • An expanded problem-focused examination
  • Medical decision-making of moderate complexity
99284
Problem(s) are usually of high severity and require urgent evaluation, but do not pose an immediate significant threat to life or physiologic function
  • A detailed history
  • A detailed examination
  • Medical decision-making of moderate complexity
99285
Problem(s) are usually 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

According to the American Medical Association’s (AMA) description of emergency E/M services:

  • An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention
  • No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.
  • Time is not a descriptive component for the emergency department levels of E/M services because the emergency department services are typically provided on a variable intensity basis. Providers often deliver care involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult for physicians to accurately estimate the time spent face-to-face with each patient.

Methods
The metrics reviewed in this eCBR are the proportion of billing for each CPT code in the E/M grouping with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your claims for CPT codes 99281-99285 at levels compared to your peers in the RRB SMAC jurisdiction.

Example of eCBR Results from eServices

Exampleof eCBR Results from eServices

 

Please be aware that the information contained within this eCBR 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.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. – 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. – 4 p.m. PT.

Educational Resources
CMS Resources

Palmetto GBA Railroad Medicare Resources