Knock Out 99285 Confusion Now – This ED Code Is Getting Noticed

coding emergency department visits

The highest level emergency department code, 99285, is popular. A comparative billing report (CBR) by eGlobalTech recently showed the national percentage of emergency department services submitted with 99285 was 55 percent. And when the highest level E/M code in a group is getting that much use, you know there’s going to be some scrutiny. Here’s a quick-start guide to 99285 to help get you on your way to better coding.

Compare the Requirements for 99281-99285

To choose an emergency department E/M code from 99281-99285, you have to look at the three key components. The code you choose must meet all three components (with a special caveat for 99285, described below).

The table below shows the components required.





Presenting Problems


Problem focused


Self-limited or minor


Expanded problem focused

Low complexity

Low to moderate severity


Expanded problem focused

Moderate complexity

Moderate severity



Moderate complexity

High severity requiring urgent eval, but not significant threat to life or function



High complexity

High severity, significant threat to life or function


Remember the 99285 Caveat to Avoid Downcoding

The descriptor for 99285 includes what’s sometimes called the emergency acuity caveat or emergency medicine caveat. Here it is: The descriptor states the code “requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status.”

In other words, a patient brought to the emergency room with a condition that is a significant threat to life may not be able to provide a comprehensive history, for example. But the encounter still may merit reporting 99285 because of the complexity and severity of the case.

Important: To support reporting 99285, the documentation should include the patient-specific reasons why an individual component could not be met. The CBR handout advises “the documentation should include differential diagnoses, procedures, diagnostic studies, interventions, and risk factors.”

Tip: If the physician can’t check all the boxes for an exam because of the patient’s clinical condition or mental status, the “within the constraints imposed” wording still applies. The wording isn’t directed only at the history portion of the code descriptor. AMA’s CPT® Assistant confirmed this way back in 2002 in the September issue.

What About You?

Do you report emergency department E/M codes? How do you ensure you have the information you need to support reporting 99285? What’s your experience with CBRs?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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