Can 99283 and 99284 Be Billed Together?

Current Procedural Terminology (CPT) codes, maintained by the American Medical Association (AMA), provide a standardized language for reporting medical services and procedures. They ensure consistent communication between healthcare providers, payers, and government programs like Medicare and Medicaid for billing and reimbursement. CPT codes 99283 and 99284 are specifically designated for Evaluation and Management (E/M) services in an Emergency Department (ED) setting. This article aims to clarify the established rules and common practices regarding the billing of these two distinct E/M codes.

Understanding Emergency Department Evaluation and Management Codes

CPT code 99283 represents an emergency department visit for the evaluation and management of a patient requiring moderate complexity medical decision-making. It applies to situations demanding moderate resources, such as diagnostic tests and low-risk interventions. Examples include mild respiratory distress or acute abdominal pain. Documentation for this level typically includes an expanded problem-focused history and examination.

CPT code 99284 signifies an emergency department visit involving a higher level of complexity than 99283. This code is used for cases requiring a detailed history, a detailed examination, and medical decision-making of moderate complexity. It addresses high-severity issues demanding urgent evaluation, but typically not an immediate threat to life. Scenarios appropriate for 99284 might include evaluating a possible fracture requiring imaging and splinting, or managing a severe asthma attack.

Fundamental Principles of Billing Evaluation and Management Services

A core principle in E/M billing dictates that typically only one E/M service code is reported per patient per day by the same provider or group for the same type of service. This practice prevents duplicate billing for services that are inherently part of a single patient encounter.

The concept of “unbundling” is strictly prohibited in medical billing, meaning that components of a service already included within a comprehensive code cannot be billed separately. E/M codes are hierarchical, with higher-level codes encompassing the work described by lower-level codes for the same type of encounter. This ensures the most appropriate and comprehensive code is selected. Furthermore, all billed services must meet the requirement of medical necessity, meaning the service must be reasonable and appropriate for the diagnosis and treatment of the patient’s condition.

Why Emergency Department Codes 99283 and 99284 Are Not Billed Together

CPT codes 99283 and 99284 represent different levels of complexity for the same emergency department visit. Only one of these codes can be selected and billed for a single patient encounter. Billing both codes for the same visit would constitute unbundling or duplicate billing for the identical service.

The National Correct Coding Initiative (NCCI) plays a significant role in preventing such dual billing. NCCI Procedure-to-Procedure (PTP) edits specifically define pairs of Healthcare Common Procedure Coding System (HCPCS) and CPT codes that should not be reported together. These edits prevent improper payments by bundling component codes or identifying mutually exclusive services. Since 99283 and 99284 denote increasing levels of the same emergency department service, NCCI edits prevent their simultaneous billing for the same date of service and patient.

Payer policies, including those from Medicare, Medicaid, and commercial insurers, align with NCCI edits and CPT guidelines to prohibit the dual billing of these codes. These policies reinforce the principle that a single emergency department encounter should be represented by a single, most appropriate E/M code.

Consequences of Incorrect Billing

Submitting incorrect medical claims, such as billing both 99283 and 99284 for the same encounter, can lead to several negative outcomes. One immediate consequence is claim denials, where insurance companies refuse to pay for the services rendered due to coding errors. This impacts the healthcare provider’s revenue cycle, causing delayed reimbursements and requiring administrative effort to correct claims.

Beyond denials, incorrect billing practices can trigger audits by payers, including government entities like Medicare and commercial insurers. During an audit, healthcare organizations may be required to refund overpayments, potentially involving substantial amounts. Repeated or intentional billing errors can also lead to more severe compliance risks, including fines, penalties, and even legal action under regulations like the False Claims Act. Such errors can also damage the provider’s reputation.

Accurate Documentation and Coding for Emergency Department Encounters

Thorough and accurate medical documentation is fundamental to supporting the appropriate E/M level chosen for an emergency department visit. The clinical notes, including the chief complaint, diagnoses, treatment plan, and all tests and imaging, must clearly justify the complexity of the service provided. This documentation serves as evidence for the billed code.

For emergency department E/M services, the appropriate level is primarily determined by the medical decision-making (MDM) complexity. MDM considers the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity/mortality associated with patient management. The documentation must explicitly reflect at least two of these three elements to support the selected E/M level, such as 99283 or 99284.

Time is not a descriptive component for emergency department E/M services when selecting the code level, unlike in some other settings. Healthcare providers and coders must stay updated with the latest CPT guidelines, NCCI edits, and payer-specific policies to ensure ongoing compliance and prevent billing errors. Regular training and internal audits help maintain coding accuracy.