High-level professional emergency department claims must be supported in medical records

Optum is requesting medical records on behalf of Blue Cross Blue Shield of Michigan for the pre-pay program. Medical records for professional emergency department PPO claims will be requested to verify that documentation supports a high-level of medical decision making for claims billed with CPT code *99285.

CPT code *99285 is used to report emergency department visits requiring a medically appropriate history and/or examination and high medical decision-making.

Here are some key documentation reminders to support CPT code *99285:

• While history and physical examination is important, it won’t be a determining factor for code selection.
• The MDM complexity should be well-documented and meet the criteria for high-level decision-making.
• High-level MDM involves reviewing and analyzing a significant amount of data, including tests, imaging studies, and coordination with other health care providers and must be clearly documented.
• High-level risk addresses situations with a high risk of complications, severe morbidity, or mortality, requiring high-level decision-making and management.

Remember, per CPT guidelines, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”

Refer to the American College of Emergency Physicians MDM Grid** for leveling guidelines.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.