CPT code 99284: Emergency department visit, high severity

What is CPT code 99284?

CPT code 99284 is one of the medical billing codes that represents and is used to describe emergency department visits for the evaluation and management (E/M) of a patient requiring a medically appropriate history and/or examination and moderate-to-high complexity medical decision making.

The emergency department services and level of care offered by the qualified health care professionals only applies when the patient presents with a condition of high severity that necessitates urgent evaluation but doesn't pose an immediate significant threat to life of physiologic function.

Common scenarios where this code may be used are when the patient is in the ER and has severe abdominal pain, moderate trauma, or systemic symptoms requiring diagnostic workup and medical intervention.

The code is used exclusively in the ED setting and does not require that the patient be new or established.

Key differentiators for 99284 from other similar codes include:

• The volume of data reviewed
• Number and type of diagnostic tests ordered
• Complexity of the medical decision making

While no specific time component is listed for ED codes, documentation must substantiate the medical necessity and complexity of services provided.

CPT code 99284 documentation requirements

Streamline administrative processes by following good medical coding and billing practices, one of which is accurate documentation. To help you out, here are the requirements for documentation.

• A moderate complexity problem
• A detailed history (HPI, ROS, PFSH)
• A comprehensive physical examination (covering at least eight organ systems)
• Clear evidence of moderate to high complexity MDM, including:
  • Multiple diagnoses or management options
  • Moderate amount/complexity of data reviewed (e.g., labs, imaging, ECGs)
  • Moderate risk of significant complications, morbidity, or mortality

Thorough documentation should support the intensity of evaluation, with clinical rationale for tests, treatments, and possible need for follow-up or observation. The provider must document interventions such as IV medications, ECG interpretation, or advanced imaging when used to justify the level of service.

CPT code 99284 billing guidelines

Optimize both the coding and claims process and the insurance billing process by keeping the following guidelines in mind:

• The code is billable for emergency medicine physicians or any qualified provider rendering care in the ED.
• Do not assign 99284 solely based on time or location; it must be backed by the complexity of the case as seen in the document that should come complete with the detailed history, examination, and evidence of the medical decision making.
• The diagnosis must support the severity level; for example, billing 99284 for a mild headache without abnormal findings may be denied.