ACEP has successfully argued—and CMS has agreed—that upper-level ED services (99284–85) are more intense than those furnished in an office-based setting. Emergency physicians are usually caring for many patients simultaneously, instituting care and medical decision making for multiple patients many times per hour. As a result, the RVUs and resulting payments are higher for ED services provided in the ED setting. It is essential that ACEP be able to continue to emphasize the intensity of our ED services, or we’ll have to face a grim reality of time-based compensation that would negatively impact our revenue. Emergency medicine is an outlier in our RVU valuation because our levels are intensity-based rather than time-based because there isn’t a good way to accurately record time for a physician juggling multiple patients in the chaotic environment of the ED.

CMS is on record as believing the higher intensity of upper-level ED services (99284–5) do not lend themselves to being furnished via telehealth. This makes it difficult for ACEP to advocate for parity in payments for ED services furnished via telehealth with those for in-person services after the PHE ends. If we argue to CMS that upper-level ED visits are not too intense for telehealth use, we risk lowering the future values of all ED services. Parity would not be advantageous should that occur. CMS and the members of the RBRVS committee that set RVU valuation at the RUC would certainly question our rationale for parity when telehealth visits seldom, if ever, have the complexity of a dozen patients and varying acuities coupled with the continual interruptions of the ED setting.

The ACEP CPT team has worked for years to get the ED E/M codes (99281-99285) added to Appendix P of the CPT code set, meaning they could be paid when furnished via telehealth. So far, those attempts have been unsuccessful because ED codes are considered more intense than office visits. Further attempts could upend the valuations we have successfully defended and increased over the past two decades.

There is clearly a need for telehealth delivery in and from a variety of geographic locations, but careful considerations need to be made if we should include 99284 and 99285 in the telehealth codes for reimbursement. These two codes represent most ED services provided in any setting, and we cannot jeopardize a possible reduction in value, especially when there are so many other potential cuts to ED payments on the horizon. This becomes even more essential as the documentation guidelines change in January 2023 and we find a new distribution of ED codes submitted for reimbursement. Many ED visits may “level up” based on those changes, and 99284 may become the most important code in our family to preserve and protect.