Emergency Room Billing CPT Codes 99281 – 99285

What is a CPT 99281 code?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99281 CPT code is a visit that has three main components:

A problem-centric history.
A problem-centric exam.
Very simple medical decision making.
Usually, the symptoms the patient presents with are low urgency, requiring little to no immediate medical care. Some of the symptoms that fit under the 99281 code are self-treatable.

This low severity Emergency Room visit requires the least comprehensive chart notes.

What is CPT 99282 code?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99282 CPT code is a visit that has three main components:

A longer problem-centric history.
A longer problem-centric exam.
Simple medical decision making.
Usually, the symptoms the patient presents with are low to moderate urgency, requiring low to moderate medical care. The severity is usually moderate to low. Some of the symptoms that fit under the 99282 code may not be self-treatable.

This low to moderate severity Emergency Room visit requires slightly more comprehensive chart notes.

What is CPT code 99283?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99283 CPT code is a visit that has three main components:

A longer problem-centric history.
A longer problem-centric exam.
Moderately complex medical decision making.
Usually, the symptoms the patient presents with are moderately severe and urgent, requiring immediate care.

This moderate severity Emergency Room visit requires more comprehensive chart notes.

What is CPT code 99284?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99284 CPT code is a visit that has three main components:

A detailed problem-centric history.
A detailed problem-centric exam.
Moderately complex medical decision making.
Usually, the symptoms the patient presents with are of high severity, requiring immediate care but “does not pose an immediate significant threat to life or physiologic function”.

What is CPT code 99285?
It is a commonly used definition of an Emergency Department visit and is used in medical billing.

A 99285 CPT code is a visit that has three main components:

A high detail problem-centric history.
A high detail problem-centric exam.
Highly complex medical decision making.
Usually, the symptoms the patient presents with are of the highest severity, posing an immediate significant threat to life or physiologic function.

SOURCE: CPT 2011, CPT Assistant

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12 thoughts on “Emergency Room Billing CPT Codes 99281 – 99285

  1. CODE 99285, I CANNOT FIND THIS CODE IN THE AMERICAN SOCIETY OF ANESTHESIOLOGIST RELATIVE VALUE GUIDE. CAN IT BE USED BY AN ANESTHESIOLOGIST FOR AN ER COMPLEX EVALUATION?
    THANK YOU

    1. Hi Sonia,

      Here is some information that you may find useful from (http://bulletin.facs.org/2013/02/coding-for-hospital-admission/):
      Emergency department (ED) consultation: Patient is admitted
      In this example, a patient presents to the ED, general surgery is consulted, and the surgeon determines that the patient requires admission to the hospital through the general surgery service. For Medicare patients, if the patient is admitted to the hospital by the general surgeon, he or she should bill an initial hospital care code (99221–99223) and not an ED visit code. Medicare requires that the admitting physician append modifier AI to the initial hospital visit code (9922X-AI). If the patient is admitted for observation, codes 99218–99220 are reported. For patients receiving hospital outpatient observation services who are then admitted to the hospital as inpatients and who are discharged on the same date, the physician should report CPT codes 99234–99236.

      For patients with insurance that follows non-Medicare CPT rules, the instructions are even more obscure. If a patient is admitted after an ED consultation and is not seen on the unit (in the intensive care unit, for example) on the date of admission, only report the outpatient consultation codes (99241–99245). If the surgeon sees the patient on the hospital unit on the date of admission, report all E/M services related to the admission with the initial inpatient admission service code (99221–99223) or initial observation care code (99221–99223). Do not report both an outpatient consultation and inpatient admission (or observation care) for services on the same day related to the same inpatient stay. (See Table 2 for the 2013 total initial observation, hospital, same day observation and discharge, and outpatient consultation facility and nonfacility RVUs.)”

      Let us know if that answers your question about consultation/complex eval. Other codes may be used, not 99285 in reference to evaluations, ie anesthesiologist evals.

  2. I recently received a bill from the hospital with a 99285 CPT code. I had abdominal pain and a bladder infection. Why was billed for the highest cpt code? Since when is a bladder infection considered an immediate threat to life? I don’t feel this is an accurate code. I feel I’m being forced to pay way to much. I’m going to call, but I don’t know what to do. It doesn’t seem to me that I was even treated as though I was facing imminent threat to life. My scans came back clear and I was sent home that evening (5 hr visit with about w hours waiting to be seen) I had no surgeries. I had a CT and ultrasound. I also already paid a bill for this. Do you think a 99285 code applies? All of my records were accessible in that hospital as well. This seems like a very dramatic step for the ED to take when they sent me home with what they labeled abdominal pain. 2 days later I was told I had a bladder infection. I was already on antibiotics, just the wrong type. My questiom, where’s the life threatening illness? I’ve had pneumonia and not been given a 99285.
    Thanks

    1. Hi Betsy,

      99281-99285 CPT codes are assigned based on the level of examination and decision-making. The highest severity code 99285 is reserved only for visits that have the highest detail problem-centric exam and highly complex medical decision making. However, as it appears in your case, this code may have been used improperly. A CPT code 99282 may have been more appropriate if you came in with initially presenting “ab pain” symptoms. It doesn’t take complex decision making or consultations like a 99285 typically might.

      If you are on Medicaid or Medicare, it is my understanding that your insurance company must cover this (as in our state of Oregon). If you are not insured, you should take a look into the state covering these emergency room costs for you completely , as there may be a program for the financially needy in your state. Please let me know how else I can help.

  3. My daughter went into the emergency room due to loss of feeling in her legs and pain radiating up one side. They coded it as a 99283 which was denied by the insurance as not an emergency but a minor illness. She ended up receiving a morphine shot and another shot for pain. How is that a minor illness!

  4. My son went to the emergency room with nausea and stomach ache, spent about 2 hours, he was checked for vital signs, checked for an influenza virus via swab test and given one pill for nausea. There were no other tests done. We were charged using 99284 code for his treatment which does not sound right based on the services performed. He was mostly attended by a nurse and had a doctor stopped by for a few minutes to listen to his chest. That was it.

    1. Thank you Dina,
      This is incorrect billing. This is almost the highest severity code they could have used. It should have been 99281 if these were the only tests they ran and he was not put under observation for a critically-perceived event. I would venture to say the chart notes would reveal they did not provide detailed documentation, longer consultation, etc to warrant such a high cpt code.

  5. Hello,
    I was recently in the energency room in regards to an accident that i was involved in. When i went in they took me to a room right away the doctor did take a while to come in which was understandable. He did explain that since i was pregnant their wasnt much they could do if something were to happen to my baby because it was so tiny. He did touch my stomach to make sure it felt okay. He did state that if i would like we could do an ultrasound but it would take hours and hours. I then decided it was better to go to my obgyn. I received an eob today and the doctor billed a 99284 eventhough he didn’t even do anything he wouldnt even use the doppler that a nurse had brought in.

    1. Thank you for the comment Myra.
      We hope everything went okay at the OBGYN. The billing department may have charged a 99284 cpt code because of the percieved danger presented to both yourself and your baby. This is normal, actually. You see, as a prudent lay reviewer, we would approve payment on such an ER claim because under the prudent lay standard – we take into account whether a mother and her unborn child were possibly in danger of being fatally injured/bodily members in danger. In this case, yes there was a possibility of that so the coding was correct — a 99284 or 99285. This is regardless of the actual outcome/tests run by the doc — it’s based on PRESENTING symptoms (perceived by patient). If you felt your child and you were in fatal danger at the onset of the visit, then they coded just fine.

  6. My daughter was passenger on ATV (yes I disapprove of her being a rider at such a young age but was not there to stop it) they hit a bush which made driver hit head on handlebars I guess. My daughter I guess hit her to only leave a reddish dollar size area above eye(no swelling or deformity) both girls crying so parents of driver take them to ER. I came maybe 15-20 mins later and met at ER. Upon arrival dad of other girl is sitting with my daughter and laughing at her doing toe touches off of cot. I asked if ok and she said I guess. I’m not a Dr..but am a EMT-Basic. I feel around and give her a quick rapid trauma exam and pain levels were 0. Might throw this in she’s 6yo. Also my best friend a Dr. and he gets there 5-10 after me. He looks at her literally not exam wise and asks her house she is and she giggles at him saying We ran into a bush. this leads up to question. Hospital bills us a 99281 and tells us if we pay at one time they will knock off 40%. I paid like +-$55. I received a bill of $1200.00 for physician and his code was a 99285. Ive read and my daughter does not meet those requirements. I call hospital and they call physician biller and agree to drop it from 99285-99283. So I’m just wondering “Before I called you out my daughter was a high priority on the verge of death traumatic case but now she isn’t?” I feel like this is fraud on so many levels. I do have private insurance.

    1. Thank you for taking the time Andy, you did the right thing contacting the hospital.

      In your daughter’s visit, it may have happened because she was a child. Children will normally get billed a higher level, though from a financial perspective, you can see it is an unreasonable charge for the duration of the visit and the outcome of the visit (no hospitalization, minimum tests ran, minimum time with doc). These types of codes may be assigned at arrival to ER, and may not be corrected when it comes to issuing the bill. Please reach out to your insurer if you haven’t already.

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