Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

The definition of 99285 includes the concept that the history, physical exam, and medical decision making (key requirements) must be met “within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status.” This concept is called the acuity caveat and can be very helpful to emergency physicians. For example, consider the limitations we face when patients are unconscious, intubated, altered, under the influence, or needing to be whisked off to the operating room by the trauma team to save their lives. Most Medicare contractors require a description of the patient’s urgent condition that prevents satisfying any of these key elements of the 99285 evaluation and management service as well as the physician’s thought process through the discussion of risk factors, the differential diagnosis, procedures, diagnostic studies, interventions, and disposition. Make sure to document why the severity of your patient’s illness and/or procedures, such as intubation on arrival, preclude or prevent performing a comprehensive history or exam.

Brought to you by the ACEP Coding and Nomenclature Committee.

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Ms. Edelberg is chief executive officer of Edelberg & Associates in Dacula, Georgia. Dr. Lempert is vice president and medical director, health care financial services, at TeamHealth, based in Knoxville, Tennessee.