Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) practitioner services 
provided on February 28, 2020 billed with code 99285. 
 
You asked the Plan to pay for the ED services. You say that you feel that this downcoding is inappropriate and 
that the physician's decision making was of high complexity as ED practitioners do not have full access to 
medical histories. The Plan denied your request. The Plan says the records do not support the billed code. 
Payment was made for code 99284 as this more accurately describes the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ED services. Our reviewer says that the 
ED treatment code reported in this case is not supported by the submitted records. Our physician reviewer 
found the enrollee is a 62-year-old woman with a history of hypertension, hyperlipidemia, breast cancer, mitral 
valve prolapse, TIA, and a tumor of the uterus, who was evaluated in the Emergency Department on 2/28/20 
with a Chief Complaint of hypertension. The enrollee reported the she developed some bilateral arm pain and 
 
 
some dull, aching substernal chest pain while walking. A family history, social history, and review of systems 
are recorded. A comprehensive physical examination was documented. An EKG and laboratory studies were 
ordered and reviewed. A decision was made to admit the enrollee. The risks of complications, morbidity, 
and/or mortality are all noted to be low. 
 
The following are documented: a comprehensive history and a comprehensive examination. The documentation 
does not support medical decision making of high complexity. There was not an extensive amount of high 
complexity data to review, and the risks of complications, morbidity, and/or mortality were not high. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ED services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department (ED) practitioner services provided on February 28, 2020 billed with 
code 99285.