Billing - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T19:01:27Z

Rossdonaldson1: /* Critical Care Billing */

2026-03-25T17:56:30Z

Critical Care Billing

← Revisión anterior		Revisión del 17:56 25 mar 2026
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	*See [[Critical care documentation]] for detailed information		*See [[Critical care documentation]] for detailed information
	*Critical care can be coded when total duration of critical care services ≥30 minutes		*Critical care can be coded when total duration of critical care services ≥30 minutes
	*Time does ~~'''~~not~~'''~~ need to be continuous		*Time does not need to be continuous
	*Must ~~'''~~exclude~~'''~~ separately billable procedures from critical care time		*Must exclude separately billable procedures from critical care time
	*Can bill E/M ~~'''~~plus~~'''~~ critical care if the E/M is for the initial evaluation before the patient becomes critical		*Can bill E/M plus critical care if the E/M is for the initial evaluation before the patient becomes critical

	==See Also==		==See Also==

Rossdonaldson1: /* Medical Decision Making (MDM) */

2026-03-25T17:55:48Z

Medical Decision Making (MDM)

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	*MDM is the primary driver of ED billing level under current CMS guidelines		*MDM is the primary driver of ED billing level under current CMS guidelines
	*MDM complexity is determined by three elements:		*MDM complexity is determined by three elements:
	**~~'''~~Number and complexity of problems addressed~~'''~~		**Number and complexity of problems addressed
	**~~'''~~Amount and complexity of data reviewed and analyzed~~'''~~ (labs, imaging, records, discussions)		**Amount and complexity of data reviewed and analyzed (labs, imaging, records, discussions)
	**~~'''~~Risk of complications, morbidity, or mortality~~'''~~ from the patient's condition or management		**Risk of complications, morbidity, or mortality from the patient's condition or management

	===How to Support Higher MDM===		===How to Support Higher MDM===
	*Document ~~'''~~differential diagnoses~~'''~~ considered (see [[Differential diagnosis documentation]])		*Document differential diagnoses considered (see [[Differential diagnosis documentation]])
	*Document independent review of ~~'''~~labs and imaging~~'''~~		*Document independent review of labs and imaging
	*Note ~~'''~~discussions with consultants~~'''~~ and other providers		*Note discussions with consultants and other providers
	*Document ~~'''~~review of external records~~'''~~		*Document review of external records
	*Note ~~'''~~prescription medications~~'''~~ ordered		*Note prescription medications ordered
	*Document the ~~'''~~risk assessment~~'''~~ including potential complications		*Document the risk assessment including potential complications
	*See [[MDM for different chief complaints]] for sample MDM documentation by chief complaint		*See [[MDM for different chief complaints]] for sample MDM documentation by chief complaint

Rossdonaldson1 at 17:54, 25 March 2026

2026-03-25T17:54:49Z

← Revisión anterior		Revisión del 17:54 25 mar 2026
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	==Background==		==Background==
	*Understanding ED billing is essential for appropriate reimbursement and documentation		*Understanding ED billing is essential for appropriate reimbursement and documentation
	*As of 2023, CMS E/M coding for ED visits is based primarily on ~~'''~~medical decision making (MDM)~~'''~~ or ~~'''~~total time~~'''~~, no longer requiring specific HPI/ROS/exam element counts for billing level<ref name="cms2023">American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>		*As of 2023, CMS E/M coding for ED visits is based primarily on medical decision making (MDM) or total time, no longer requiring specific HPI/ROS/exam element counts for billing level<ref name="cms2023">American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>
	*ED E/M visits use CPT codes 99281-99285; [[Critical care documentation\|critical care]] uses 99291-99292		*ED E/M visits use CPT codes 99281-99285; [[Critical care documentation\|critical care]] uses 99291-99292
	*Proper documentation directly impacts revenue and medicolegal protection		*Proper documentation directly impacts revenue and medicolegal protection
Línea 24:		Línea 24:

	==Medical Decision Making (MDM)==		==Medical Decision Making (MDM)==
	*MDM is the ~~'''~~primary driver~~'''~~ of ED billing level under current CMS guidelines		*MDM is the primary driver of ED billing level under current CMS guidelines
	*MDM complexity is determined by three elements:		*MDM complexity is determined by three elements:
	**'''Number and complexity of problems addressed'''		**'''Number and complexity of problems addressed'''

Danbot: Major rewrite: updated for 2023 CMS guidelines, clean billing table, MDM as primary driver section, legacy requirements section, critical care billing, internal links, documentation pages template

2026-03-24T11:05:02Z

Major rewrite: updated for 2023 CMS guidelines, clean billing table, MDM as primary driver section, legacy requirements section, critical care billing, internal links, documentation pages template

Show changes

TannerLeeFrey: /* Medical Decision Making (MDM) */

2021-11-19T08:34:14Z

Medical Decision Making (MDM)

← Revisión anterior		Revisión del 08:34 19 nov 2021
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	*Order prescription medications		*Order prescription medications

	*CMS MDM example.		'''CMS MDM example.'''

	Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.		Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.

TannerLeeFrey at 08:33, 19 November 2021

2021-11-19T08:33:35Z

← Revisión anterior		Revisión del 08:33 19 nov 2021
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	*Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)		*Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)
	*Order prescription medications		*Order prescription medications

			*CMS MDM example.

			Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.

	==RVU For Level of Service<ref>CMS Clinical Fee Schedule for 2021 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched</ref>==		==RVU For Level of Service<ref>CMS Clinical Fee Schedule for 2021 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched</ref>==

Neil.m.young: /* RVU For Level of Servicehttp://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/ */

2021-03-02T17:11:53Z

RVU For Level of Servicehttp://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/

← Revisión anterior		Revisión del 17:11 2 mar 2021
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	*Order prescription medications		*Order prescription medications

	==RVU For Level of Service<ref>~~http~~://www.~~acep~~.~~org~~/~~Clinical---Practice-Management~~/~~Top~~-20-ED-~~Reimbursement~~-~~Codes-2016~~/</ref>==		==RVU For Level of Service<ref>CMS Clinical Fee Schedule for 2021 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched</ref>==
	*99281 (Level 1) = 0.60 RVUs		*99281 (Level 1) = 0.64 RVUs
	*99282 (Level 2) = 1.17 RVUs		*99282 (Level 2) = 1.24 RVUs
	*99283 (Level 3) = 1.75 RVUs		*99283 (Level 3) = 2.10 RVUs
	*99284 (Level 4) = 3.32 RVUs		*99284 (Level 4) = 3.57 RVUs
	*99285 (Level 5) = 4.90 RVUs		*99285 (Level 5) = 5.16 RVUs
	*[[Critical care documentation\|99291 (Critical Care)]] = 6.31 RVUs 1st hr		*[[Critical care documentation\|99291 (Critical Care)]] = 8.19 RVUs 1st hr
	**Critical Critical care can be coded when the total ~~duration~~ duration of time spent by a provider in providing critical care services to a critically ill or critically injured patient is at least 30 minutes, even if the time spent is not continuous.		**Critical Critical care can be coded when the total duration of time spent by a provider in providing critical care services to a critically ill or critically injured patient is at least 30 minutes, even if the time spent is not continuous.

	==See Also==		==See Also==

Neil.m.young: /* CMS Requirements for Billing */

2021-03-02T17:02:59Z

CMS Requirements for Billing

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	*Neurologic		*Neurologic
	*Psychiatric		*Psychiatric

			===Medical Decision Making (MDM)===
			MDM complexity can be increased by documenting the following things as applicable
			*Discussing differentials
			*Review labs as it relates to the case
			*Independently review imaging
			*Note discussions with consultants
			*Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)
			*Order prescription medications

	==RVU For Level of Service<ref>http://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/</ref>==		==RVU For Level of Service<ref>http://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/</ref>==

Modanq: Added Physical Exam and ROS

2018-12-30T06:03:10Z

Added Physical Exam and ROS

@@ Línea 49: / Línea 49: @@
 **Marital Status
 **Sexual History
 ==RVU For Level of Service<ref>http://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/</ref>==

← Revisión anterior		Revisión del 19:01 25 mar 2026
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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Critical care documentation]]
	*[[MDM for different chief complaints]]

	{{Documentation pages}}		{{Documentation pages}}