CPT code 99283: Emergency department visit, moderate complexity

What is CPT code 99283?

CPT code 99283 represents an emergency department (ED) visit that requires a moderate-complexity evaluation and management (E/M) service. Healthcare providers use this code when managing patients with low-to-moderate-severity conditions that require urgent evaluation but do not pose an immediate significant threat to life or long-term bodily function.

Under CPT guidelines, 99283 typically involves an expanded problem-focused history, an expanded problem-focused examination, and moderate-complexity medical decision-making. In many real-world cases, however, providers often perform a detailed examination and gather a detailed history to better understand the patient's situation and risks. This is especially important when dealing with conditions that could potentially worsen if not appropriately managed.

Examples of services billed under 99283 include care for minor fractures, moderate asthma exacerbations, simple lacerations requiring sutures, or moderate infections such as cellulitis or urinary tract infections. These cases require emergency department services because prompt diagnosis and treatment are needed, even though they are not life-threatening emergencies.

It's important to note that emergency department services do not distinguish between new or established patients—all patients are considered new for E/M coding purposes in the ED. Regardless of prior treatment relationships, the visit must meet the specific criteria based on history, examination, and medical decision making.

Documentation requirements

Proper and accurate documentation is essential to support the use of CPT 99283 and comply with payer expectations. Documentation must include:

• Expanded problem-focused history: Capture a history of the present illness (brief or extended), a review of pertinent systems, and a relevant past medical, family, or social history.
• Expanded problem-focused examination: Include a limited but specific physical exam covering affected organ systems or body areas based on the presenting complaint.
• Medical decision making of moderate complexity: Document the number and complexity of diagnoses or management options considered, the amount and complexity of data reviewed (e.g., labs, imaging), and the level of risk to the patient.
• Clinical context: Clearly describe the urgency and necessity for ED evaluation, showing why the patient required immediate attention despite their condition being of low to moderate severity.
• Qualified provider signature: Ensure the note is signed and dated by a qualified healthcare professional providing the service.

Billing guidelines

Follow these key billing and coding guidelines for CPT 99283:

• Patient type: ED patients are considered new for coding purposes; previous relationships with providers are not considered.
• Service setting: Only bill 99283 when services are provided in a facility classified as an emergency department.
• Time is not the sole factor: Unlike some outpatient E/M services, time is not typically the primary determinant for ED coding. Instead, code selection is based on history, examination, and medical decision-making.
• Medical necessity: The severity of the presenting problem must support the moderate complexity level. Conditions like chest pain requiring EKGs, dehydration needing IV fluids, or moderate trauma typically qualify.
• Accurate selection between adjacent codes: Do not upcode or downcode—ensure the documented services meet the threshold for expanded history and exam, and moderate medical decision making. Cases with minimal exam and decision making may better fit CPT 99282, while more complex cases needing comprehensive evaluation might fall under CPT 99284.

Other relevant CPT codes

• 99281: ED visit for a self-limited or minor problem, may not require a physician.
• 99282: ED visit with low complexity evaluation and management.
• 99284: ED visit with moderate to high severity, requiring urgent evaluation with high complexity MDM.