Emergency Department

Evaluation & Management Services

E/M is divided into broad categories such as
Office Visits (Physician’s Visit) – Meeting between a patient and a physician.
Hospital Visits - Overnight stay, Inpatient.
Consultations - Physician referring the patient to other physician.

New Patient: A patient who has not received any professional services from the physician/another
physician /qualified healthcare professional of the exact same specialty & subspecialty that belongs
to the same group practice within past three years.

Established Patient: A patient who has received professional services from the physician/another
physician /qualified healthcare professional of the exact same specialty & subspecialty that belongs
to the same group practice within past three years.

Components of E/M
KEY COMPONENTS: History, Examination & MDM
CONTRIBUTING FACTORS: Counseling, Coordination of care, Nature of presenting problem &Time

KEY COMPONENTS
a. History
This is the first component which includes CC, HPI, ROS & PFSH

1. Chief Complaint (CC): Describing the symptoms, problem, condition, diagnosis or other
factors by the patient.

2. History of Present Illness (HPI): Description of present illness including EIGHT elements
Brief: 1-3 elements, Extended: 4 or more elements.
Elements
Location: Where the problem occurs (anatomical part) - Leg pain
Quality: Description of pain - Burning, Stabbing
Severity: How hard the problem is (1 – 10 rating) - Mild, Moderate, Severe
Duration: How long it is - Since 2 years, Past month
Context: How it happened – Scratched by Cat
Timing: When it occurs - At night, frequently
Modifying factors: Things that make symptoms worse or better- Pain when bends
Asso. Signs & Symptoms: Problem that occurs primary problem – Chest pain leads to SOB

3. Review of Systems (ROS): An inventory of body systems obtained through a series of

questions seeking to identify signs/symptoms they may experiencing or has experienced (by
the patient)

Systems
Constitutional symptoms – fever, weight gain
Eyes – blurred vision, double vision
Ears, Nose, Mouth, Throat (ENT) – sinuses, difficulty in swallowing
Cardiovascular - Chest pain, irregular heart beat
Respiratory - SOB, Wheezes

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Gastrointestinal – Heartburn, Stomach pain

Genitourinary –Dysuria, Urinary frequency
Muscoskeletal – Pain, Swelling
Integumentary – Rashes, Lumps
Neurologic – Numbness, Headache
Psychiatric – Feelings, Sleeping habits
Endocrine – Thirst, Sweating
Lymphatic/Hematologic – Lymph nodes, Lymph vessels
Allergic/Immunologic – Allergies, Reactions

Determining the Level of ROS

Problem (Pertinent ROS)-involves review of one body i.e., related directly to the presenting
problem.
Extended ROS – involves review of body systems that are related directly to the presenting problem
as well as additional body systems (2-9 systems)
Complete ROS – includes review of 10 or more systems

4. Past Family Social History (PFSH)

 PH – review of prior illness, injuries, operations, hospitalizations, medications etc.,
 FH - review of medical events in the patient’s family that are hereditary/place at risk.
 SH – review of habits such as smoking, drug use, alcohol, occupations.

History Type CC HPI ROS PFSH

Problem Focused(PF) Required Brief(1-3) N/A N/A
Expanded PF Required Brief(1-3) Problem Pertinent(1) N/A
Detailed Required Extended(4+) Extended(2-9) Pertinent(1)
Comprehensive Required Extended(4+) Complete(10+) Complete(2-3)

Levels of PFSH
Pertinent – Atleast one item for one of the areas of past history.
Complete – Atleast two specific from past history for ESTABLISHED PATIENT or discussion of all three
areas of the past history for a NEW PATIENT.

b.Examination
This is the second component of the 3 key components used to determine the level of E/M service.
Like history, there are four exam types – PF, EPF,D & C to determine the extent of examination
performed, see descriptions below:

Eyes Ears, Nose, Mouth & throat

Cardiovascular Psychiatric
Gastrointestinal Respiratory
Muscoskeletal Genitourinary
Neurologic Integumentary
Hematologic/Lymphatic/Immunologic

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Exam Type Performed & Documented

PF Limited exam of one body or organ system
EPF Limited exam of affected body area/organ system + any other symptomatic or
related body area/organ system ( 2-7 body areas and/or organs systems)
D Extended exam of affected body area(s)/organ system(s) + other symptomatic or
related body areas/organ systems ( 2-7 body areas and/or organs systems with at
least 1 in detail
C General multisystem
8 or more findings about the organ systems and/or body areas

c. Medical Decision Making (MDM)

This is the third component used in determining a level of service includes subjective area
Which makes it one of the most difficult components to determine? There are 4 types:

 Straight forward
 Low complexity
 Moderate complexity
 High complexity

Table A: Number of Diagnosis & Management Options

Category Value
Self Limited or minor 1
Established problem, Stable or improved 1
Established problem, worsening 2
New problem, no additional workup planned 3
New problem, additional workup planned 4

Table B: Amount and/or Complexity of Data Reviewed

Data type Point
Labs ordered and/or reviewed 1
X-ray ordered anchor reviewed 1
Medicine section ordered and/or reviewed(EMG,PT etc.,) 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than the patient 1
Review & summary of old records and/or discussion with other health provider 2
Independent visualization of images, tracing 2

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Table C: Table of Risk (highest one in any one category determines overall risk)

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Emergency Department

An ED is defined as an organized hospital-based facility for an unscheduled episodic service

to patients who present for immediate medical attention (24hours a day).

Scoring MDM must meet 3 out of 3

Component 99281 99282 99283 99284 99285

HPI 1-3 1-3 1-3 4 4
ROS 0 1 1 2-9 10+
PFSH 0 0 0 1 2
PE 1 2-4 2-4 2-7 8+

Scoring MDM must meet 2 out of 3

99281 99282 99283 99284 99285

Management options 1 2 3 3 4
Data Reviewed NA NA 1 1-3 4
Level of Risk Minimal Low Low moderate High moderate High

Modifiers
25 - Indicates that on the day of a procedure, the patient's condition required a significant,
separately identifiable E/M service

50 – Bilateral Procedures

51 - Multiple Procedures

54 – Indicates when one physician performs a surgical procedure and another provides
preoperative and/or postoperative management

57 - Decision for Surgery

59 - Indicate that a procedure or service was distinct or independent from other

services performed on the same day

76 – Repeat procedure by same physician; use when it is necessary to report repeat

procedures performed on the same day.

77 - Repeat procedure by another physician; use when it is necessary to report repeat

procedures performed on the same day.

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Emergency Department

Critical Care
(Time based code – minimum 30 minutes)

This can be defined as direct delivery by the physician for life threatening conditions (shock,
hepatic failure etc)/critical illness or injury.

Organ System Failure

 Central nervous system failure – stroke

 Circulatory failure – Acute MI
 Hepatic failure – Encephalopathy
 Renal failure – Hypokalemia
 Metabolic failure – Severe Acidosis
 Respiratory failure – Pneumonia

What counts Critical Care time?

 Beside Patient care
 Reviewing ancillary studies
 Discussion with family
 Bundled procedures
 Chart documentation & completion

Bundled Procedures Unbundled Procedures

Cardiac output Endotracheal intubation
Chest x-rays CPR(Cardiac Pulmonary Resuscitation)
Pulse oximetry Triple Lumen Catheter Insertion
Blood gases Transvenous pacer
Computer data,Transcut.Pacing EKG interpretation
Ventilatory management
Vascular access
Gastric intubation

Clinical Conditions Consistent with Critical Care

 Severely altered mental status
 Cardiac or respiratory arrests
 Airway compress
 Immediate surgery(trauma, ruptured ectopic, perforated viscous,AAA)

Less than 30 minutes Appropriate E/M codes

30-74 min (30 – 1 hr 14 min) 99291
75-104 min (1 hr 15 min – 1 hr 44 min) 99291,99292
105-134 min ( 1 hr 45 min – 2hr 14 min) 99291,99292 X 2
135-164 min (2 hr 15 min – 2hr 44 min) 99291,99292 X 3
165-194 min (2 hr 45 min – 3 hr 14 min) 99291,99292 X 4
195 min or longer (3 hr 15 min- etc 99291,99292 as appropriate

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CPT Modifiers
A Modifier provides the means by which the reporting physician/service can indicate that a service
or procedure that has been performed has a specific circumstance but not changed in its definition
or code. A modifier may be used to indicate whether

 A service or procedure has a professional component

 A service or procedure has a technical component
 A service or procedure was performed by more than one physician and/or in more than
one location
 Only part of a service was performed
 A bilateral procedure was performed
 A service or procedure was provided more than once
 Unusual events occurred
 A service or procedure was performed on a specific site
 An add-on or additional service was performed

Modifier Description Reimbursement Impact

22 Unusual procedural services Antepartum E&M visits due to
pregnancy complications that exceed
the typical care (14 visits) will be given
individual consideration when modifier
is appended to the global obstetrical
codes (CPT codes 59400, 59510, 59610
or 59618) and supported by the medical
documentation.
23 Unusual anesthesia Modifier use will not impact
reimbursement
24 Unrelated evaluation and After appropriate use of modifier is
management service by the same validated, 100% of the fee
physician during a postoperative schedule/allowable amount; E&M
period services billed with modifier 24 when
the diagnosis code is related to the
surgical service will be denied
25 Significant, separately identifiable See Evaluation & Management Policy for
E&M service by the same physician specific details
on the same day of the procedure or
service
26 Professional component Modifier is used for procedures subject
to 26 modifier as defined by CMS. Based
on fee schedule/allowable amount
27 Multiple outpatient hospital E&M Modifier use will not impact
encounters on the same date reimbursement
32 Mandated services Modifier use will not impact
reimbursement
47 Anesthesia by surgeons No additional reimbursement is allowed
for anesthesia by a surgeon, assistant
surgeon, nursing staff/ non
anesthesiologist professional during a
procedure

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50 Bilateral procedure (see Bilateral Reimbursed at 50% of the fee

Services Policy) schedule/allowable Primary procedure is
reimbursed at 100% of the fee
schedule/allowable, subsequent
procedures reimbursed at 50% of the fee
schedule/allowable amount
51 Multiple procedures Primary procedure is reimbursed at
100% of the fee schedule/allowable,
subsequent procedures reimbursed at
50% of the fee schedule/allowable
amount
52 Reduced services Reimbursed at 50% of the fee
schedule/allowable amount
53 Discontinued procedure Reimbursed at 25% of the fee
schedule/allowable amount
54 Surgical care only Reimbursed at 80% of the fee
schedule/allowable amount
55 Postoperative management only Reimbursed at 10% of the fee
schedule/allowable amount
56 Preoperative management only Reimbursed at 10% of the fee
schedule/allowable amount
57 Decision for surgery Modifier use will not impact
reimbursement
58 Staged or related procedure or Modifier use will not impact
service by the same physician during reimbursement
postoperative period
59 Distinct procedural service After appropriate use of modifier is
XE-Separate Encounter validated, claims submitted with
XP-Separate Practitioner operative/medical notes will be
XS-Separate Organ/Structure reviewed to determine whether
XU-Unusual Separate Service procedure code is distinct or
independent from other services

62 Two surgeons Reimbursed at 62.5% of the fee

schedule/allowable amount
63 Procedure performed on infants less Modifier use will not impact
than 4 kg. reimbursement
66 Surgical team Reimbursement after individual
consideration and review of operative
notes
73 Discontinued outpatient procedure Reimbursed at 50% of the fee
prior to anesthesia administration schedule/allowable amount
74 Discontinued outpatient procedure Reimbursed at 70% of the fee
after anesthesia administration schedule/allowable amount
76 Repeat procedure by same physician Modifier use will not impact
reimbursement
77 Repeat procedure by another Modifier use will not impact
physician reimbursement
78 Return to the operating room for a Reimbursed at 80% of the fee
related procedure during the schedule/allowable amount
postoperative period

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79 Unrelated procedures or service by Modifier use will not impact

the same physician during the reimbursement
postoperative period
80 Assistant surgeon Reimbursed at 16% of the fee
schedule/allowable amount
81 Minimum assistant surgeon Reimbursed at 16% of the fee
schedule/allowable amount
82 Assistant surgeon (when qualified Reimbursed at 16% of the fee
resident surgeon not available) schedule/allowable amount
90 Reference (outside) laboratory Modifier use will not impact
reimbursement
91 Repeat clinical diagnostic laboratory Modifier use will not impact
test reimbursement
AS Physician assistant, nurse Reimbursed at 16% of the fee
practitioner or clinical nurse schedule/allowable amount
specialist services for assistant at
surgery
TC Technical component For procedures subject to TC modifier as
defined by CMS

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Interview Questions

1995 & 1997 guidelines difference?

1995 examinations are based on the body systems(digestive system, respiratory system, consider
them as 2 elements) while 1997 examinations are based on bullets outlined through specific
system examinations( digestive system: RUQ pain, LLQ pain, consider them as 2 elements)

Difference between critical care and emergency care?

Critical care produced in life threatening situations & Emergency care is a two way voice
communication with ambulance or outside the hospital

What is the basic difference between emergency and outpatient department?

An organized hospital based facility of unscheduled episodic services to patients who present for
immediate medical attention (24/7)
A medical establishment dept. runs by several specialists working in cooperation and sharing the
same facilities (given medical treatment or advice, often connected to a hospital)

PQRS: Physician Quality Reporting System (append to MI, Chest pain, Pneumonia etc.,)

Detailed history & Comphrensive history (or) Elements for 99284, 99285?

Elements of HPI? (Know the difference for each element)

Key Components (3) & Contributing factors (4)?

History (CC, HPI, PFSH & ROS) Examination & MDM (Table A,B & C)

How to pick up the level the based on table A,B, C?

Requirements to code critical care?

Critical care bundled & unbundled services?

ROS systems & PE systems?

Elements as per level?

History and Components of history?

Explain MDM table (A,B,C)?

Treatment options in ED level?

Component (technical & professional)?

Modifiers used in ED and explain them?

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Questions on Procedures
Minor Fractures?
Nose, clavicle, sternum, coccyx, 5th metacarpal, 5th metatarsal

When you will code Fracture care?

Have to check for X-ray, pain management & definitive care(Note : only for minor fractures)
Fracture care
Done by orthopedician not but ED physician
Minor(Non displaced) – Nose, rib , clavicle, sternum, coccyx, 5th metacarpal, 5th metatarsal
Major(Reduction) - X-ray, pain management, splint

Definitive care & Restorative care?

DC done by ED physician in the ED
RC done by orthopedician not in the ED or referring to orthopedician by the ED physician for check

Fracture reduction?
Manipulation should be done and procedure should be successful

Epistaxis?
Simple – Silver nitrate applying
Complex – Packing, nasal balloon, rhino rocket, Vaseline gauze, wick placement

Abscess?
Simple (dressing)
Complex (Packing or I & D from both hands…have to code complex)

Laceration repair?
Simple (Non-layered closure) – Single layered/Superficial Closure.
Intermediate (Layered closure) – Layered closure with extensive cleaning & debridement.
Complex – Intermediate with extensive cleaning and debridement
Note: Never code Complex in OP always have to code in IP settings)

Requirements to code Intubation?

Size of the tube, X-ray performed and procedure should be successful

Lumbar puncture?
Severe headache for identifying (may be) viral meningitis, migraine – L2 – L4.

Central Venous Access Device/Procedure(CVAD)

Centrally:Jugular,subclavian,femoral,inferion,superior venacava
Peripheral:Basilic,Cephalic,peripheral vein

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