Revenue Cycle

Quiz: Billing for an emergency room visit with extensive nursing care

Medicare Update for CAHs, October 17, 2012

A Medicare beneficiary was seen in the hospital emergency department and required extensive nursing care. The hospital coded the facility services it provided as a level five emergency department service (99285). The physician in the emergency department correctly coded her services as a level-three emergency department service (99283) based on more limited care (an expanded problem-focused history, an expanded problem-focused exam, and medical decision-making of moderate complexity.)

Which of the following statements is most correct regarding the services the hospital provided in connection with this emergency department encounter?

a)     The hospital should not bill an emergency department CPT code because the emergency department facility services are bundled in with the physician’s services under the Medicare outpatient prospective payment system.

b)    The hospital may bill a 99285 even if doing so would be inconsistent with the CPT guidelines for 99285 so long as 99285 reasonably reflects the hospital resources expended in connection with this encounter and the hospital is consistent in its use of the emergency department codes.

c)     The hospital should bill a 99283 because that is the correct CPT code for an emergency department encounter involving an expanded problem-focused history, a expanded problem-focused exam and medical decision making of moderate complexity.


The correct answer is B. Hospitals are not required to follow the CPT guidelines when assigning codes for emergency department and clinic visits. Hospitals may develop their own coding system for assigning E&M levels for emergency department and clinic visits so long as the coding system “reasonably relates the intensity of hospital resources to the different levels of HCPCS codes” and the hospital complies with certain other principles published by CMS. <72 Fed. Reg. 66805>

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