CPT codes for Emergency Department (ED) visits are grouped in the 99281 through 99285 range, distinguishing between various levels of service intensity. CPT 99284 is specifically used to designate a high-level evaluation and management service provided in the emergency setting. This code is assigned based on the complexity of the medical work performed, not the amount of time spent with the patient.
Defining CPT Code 99284
CPT code 99284 represents an Emergency Department visit for the evaluation and management of a patient requiring a high level of work. The presenting problem is generally of high severity, demanding urgent attention and evaluation. This code is appropriate for conditions requiring significant investigation, but which do not pose an immediate, life-threatening risk necessitating critical care intervention.
A patient presenting with a severe asthma attack that stabilizes after initial treatments, or new-onset chest pain requiring an electrocardiogram (ECG) and cardiac enzyme tests, are common scenarios for this level of service. Another example includes a patient with severe abdominal pain needing diagnostic imaging and intravenous fluids. The defining characteristic is the need for prompt, comprehensive evaluation and management of a condition with moderate potential for complication.
Documentation Requirements for Level 4
Assigning CPT 99284 is based on three key components documented in the patient’s medical chart: history, physical examination, and the complexity of Medical Decision Making (MDM). For a Level 4 visit, the documentation must support a detailed history, a detailed examination, and MDM of moderate complexity. All three elements must meet the specified criteria to justify the use of this code.
A detailed history involves a review of the patient’s current illness, a multi-system review of symptoms, and a complete past, family, and social history. The detailed physical examination requires the physician to assess the affected body area and other related organ systems. This ensures a broad clinical picture is established before treatment decisions are made.
The MDM component must be of moderate complexity. This complexity is determined by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or morbidity associated with the patient’s condition. For moderate MDM, the physician must consider multiple possible diagnoses and review complex data, such as advanced imaging or specialized lab results. The patient’s condition must also carry a moderate risk of complications or death without treatment, such as a possible fracture requiring surgery or a complex infection requiring immediate intravenous antibiotics.
Placing 99284 on the Emergency Department Scale
The CPT codes for Emergency Department services range from 99281 (lowest severity) to 99285 (highest severity). CPT 99284 occupies the middle-upper tier of this scale. The lower level, CPT 99283, typically involves an expanded problem-focused history and examination with Medical Decision Making of low complexity. This code is used for patients with moderate severity conditions, such as a minor fracture requiring a simple X-ray and splinting, where the diagnostic pathway is straightforward.
CPT 99284 is differentiated from the highest level, CPT 99285, by the immediate threat to life. Level 5, CPT 99285, is reserved for patients with conditions of high to extreme severity that pose an immediate threat to life or major physiological function, often requiring critical care interventions. The documentation for 99285 requires Medical Decision Making of high complexity, signifying a greater number of diagnoses, extensive data review, and a higher risk of morbidity or mortality. Therefore, 99284 serves as the standard for serious but stable emergencies, requiring comprehensive work-up but not immediate life support.
Financial Implications for Patients
The assignment of CPT 99284 impacts the cost of the emergency visit and the patient’s financial responsibility. Because it signifies a higher level of complexity and physician work, the charge associated with a Level 4 visit is significantly higher than lower-level services, reflecting the increased resources used, such as advanced imaging and specialized laboratory tests.
This higher charge influences the amount billed to the patient’s insurance and the patient’s out-of-pocket costs, including co-pays, co-insurance, and deductibles. Insurers often scrutinize claims submitted with CPT 99284 because of the expense, ensuring the documentation fully supports the moderate complexity of the MDM. If an insurer determines the documentation only supports a lower level of service, they may “downcode” the claim, reimbursing the provider at the lower rate, which can lead to billing disputes.