Comparative Billing Reports

CBR201709 Emergency Department Services FAQs

Question Categories

General

Clinical and Billing

Report Specifics

 

General

Why were emergency department (ED) services selected as a topic for a CBR?

We selected this topic because costs for Medicare emergency department services are increasing. According to an Office of Inspector General (OIG) report, billing of lower level emergency department codes is declining while billing of higher level codes is increasing. The OIG determined that from 2001 to 2010, “Physicians’ billing of the highest level code (99285) rose 21 percent, increasing from 27 to 48 percent.” To view the entire article, select the following link: Coding Trends of Evaluations and Management Services

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What is the purpose of a comparative billing report (CBR) on emergency department services?

CBR201709 was created to inform providers of all specialties about their billing and payment patterns on claims for emergency department services. This CBR examines Current Procedural Terminology (CPT®) codes 99281 through 99285, and included only Fee-for-Service Medicare (Original Medicare) claims for services rendered from July 1, 2016 through June 30, 2017. For more information about CBRs, please select this website link titled Comparative Billing Reports.

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What is the focus of CBR201709? 

CBR201709 is an analysis of emergency department services and focuses on the following metrics:

  • Percentage of services billed with CPT® code 99285
  • Percentage of services appended with modifier 25
  • Average allowed charges for all Medicare Part B services per visit

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Will I be audited because I received a CBR letter?

The CBR team does not have access to review the medical information needed for claims audits. As such, we do not conduct audits; however, we do encourage providers to take advantage of the self-audit resources available on the CBR web page located at this link: Self-Audit Help.

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Has Medicare changed the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?

The CBR is informational and educational and does not alter, change or negate any of the documentation and billing requirements established by the MACs. For questions about billing related to specific claims, you should always contact your MAC. Your MAC’s contact information can be found at the following link: Review Contractor Directory – Interactive Map.

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Clinical and Billing

 

How can I determine which emergency department services code to bill?

The Table below shows the CPT® codes and definitions covered in this CBR.  The history, examination, and medical decision making are the key components in selecting the level of emergency department services.

CPT®Code

History/

Examination

Medical Decision

 Making

99281

Problem focused

Straight forward

99282

Expanded problem focused

Low complexity

99283

Expanded problem focused

Moderate complexity

99284

Detailed

Moderate complexity

99285

Comprehensive

High complexity

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Is it necessary to document the time spent with a patient in the emergency department?

Medicare does not require documentation of actual time for emergency department services, as providers must multi-task and can have multiple encounters with a number of patients over an extended period of time. Therefore, it can become very difficult for physicians to accurately estimate the time spent with each patient.

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Is there a difference in billing for new patients and established patients who are treated in the emergency department?

There is no distinction made between new and established patients who receive emergency department services. Providers should bill CPT® codes 99281 – 99285 only for emergency department services, whether patients are new or established.

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Under what circumstances can modifier 25 be appended to emergency department services codes?

If you have questions about a specific claim appended with modifier 25, please contact your MAC. With that said, the CPT® Professional Edition Manual (aka CPT® Manual) states that modifier 25 should be used to describe a “significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.” Modifier 25 is required when an E/M emergency department services code is billed on the same day as a minor procedure, and when the service is above and beyond what would normally be required for the procedure. For more information, please see the CPT® Manual, which is available from the American Medical Association (AMA) at the following web link: AMA Store.

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Will Medicare pay for services provided in the emergency department if the services are not really emergencies?

Yes. As long as patients are registered and treated in the emergency department, emergency department codes are payable even if the services provided are not true emergencies. Providers should bill these type of services with the lower level emergency department codes.

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If I provide emergency care for a patient in my office, can I bill emergency department codes?

According to Chapter 12 of the Medicare Claims Processing Manual, “Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department.” For more information about billing, select the following web link: Claims Processing Manual, (Chapter 12, Section 30.6.11).

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Will Medicare pay for emergency department services when a patient is admitted to the hospital from the emergency department?

If a patient is admitted to the hospital from the emergency department or from another setting (such as a nursing home or physician’s office), all of the services performed by the physician on the same date as the admission are considered part of the initial hospital care. Medicare will not pay for both the initial hospital care and the emergency department service by the same physician on the same date of service. Please select the following web link for more information about hospital admission: Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.1.

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Can providers bill both emergency department services and hospital observation for patients who are treated in the emergency department, and then moved to observation?  

According to Chapter 12 of the Medicare Claims Processing Manual, physicians can bill emergency department codes in addition to observation care codes “for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge…There must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient encounter.” Only the ordering physician will receive payment for initial observation care. All other physicians who evaluate or consult during observation must bill the appropriate new or established office, or outpatient service codes. For more information, select the following web link: Medicare Claims Processing Manual, Chapter 12, Sections 30.6.8, 30.6.11.

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What codes should be reported if a patient is in critical condition when he/she arrives in the emergency department?

Since the patient arrives in the emergency room in critical condition, Medicare will pay for critical care services (CPT® codes 99291 and 99292), as long as the services meet the definition of critical care; however, Medicare will not pay for emergency department services provided on the same day as critical care by the same physician to the same patient. According to Chapter 12 of the Medicare Claims Processing Manual, “Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” For complete details about critical care, select the following web link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.12.

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Report Specifics

How are the peers defined?

A single rendering provider was identified by National Provider Identifier (NPI). For this CBR, each provider is compared to two peer groups:

  • State: All rendering Medicare providers practicing in the provider’s state  billing emergency department services
  • National: All rendering Medicare providers in the nation billing emergency department services

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How were claims selected for review for CBR201709?

We analyzed data for over 130,000 fee-for-service Medicare providers with claims submitted with CPT® codes 99281 through 99285. The data was pulled on September 12, 2017 from the Integrated Data Repository (IDR) covering dates of service between July 1, 2016 and June 30, 2017. If you would like more information about the IDR, select the following web link: CMS Integrated Data Repository (IDR).

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How were providers selected to receive a CBR?

After analyzing the data for each individual provider, we chose those providers who were Significantly Higher than their peers in at least one of the metrics calculated. Additionally, each recipient had at least $50,000 in allowed charges for emergency department services and saw at least 200 beneficiaries. These thresholds are at or above the 80th percentile of all emergency department providers.

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What do the comparisons mean?

There are four possible outcomes for the comparisons between the provider and the peer groups:

  • Significantly Higher – the provider’s value is higher than the peer value and the statistical test confirms significance
  • Higher – the provider’s value is higher than the peer value, but the  statistical test does not confirm significance
  • Does Not Exceed – the provider’s value is not higher than the peer value
  • N/A (not applicable) – the provider did not have sufficient data for comparison

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What does Table 1 mean?

Table 1 provides the key components for the CPT® codes that are the focus of this CBR. For an example of this table, select the following web link: CBR201709 Sample CBR.

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What is the significance of Table 2?

Table 2 is titled Summary of Your Utilization of Emergency Department Services. This table lists Allowed Charges, Allowed Services, distinct Visit Count, and distinct Beneficiary Count for each CPT® code. In addition, an overall Total row is included. To view the sample of Table 2, select the following web link: CBR201709 Sample CBR.

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How do you explain Table 3?

Table 3 provides a statistical analysis of the Percentage of Services Billed with CPT® Code 99285. It is calculated as the Number of Services with CPT® Code 99285 divided by the Total Number of Services, and then multiplied by 100. To view the results for each state and the nation, select the following web link: CBR201709 Statistical Debriefing.

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What does Table 4 show?

Table 4 provides a statistical analysis of the Percentage of Services Appended with Modifier 25. To calculate this metric, the Number of Services with Modifier 25 is divided by the Total Number of Services, and then multiplied by 100. If interested in seeing the results for each state and the nation, select the following web link: CBR201709 Statistical Debriefing.

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What is the meaning of Table 5?

Table 5 provides a statistical analysis of the Average Allowed Charges for all Medicare Part B Services per Visit submitted by the same provider on the same date of service as the emergency department (ED) service. It is calculated as the Total Allowed Charges for All Part B Services at ED divided by the Total Number of Visits. To view results for each state and the nation, select the following web link: CBR201709 Statistical Debriefing.

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