Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285, an 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 provided on December 12, 2021. 
 
You asked the Plan to pay for code 99285, an 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. You say that code 99285 is supported by the medical 
documentation. The Plan denied your request. The Plan says code 99285 is not supported by the medical 
documentation.  
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 an 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. 
 
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 code 99285, an 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. Our reviewer says that code 
99285 is not supported by the medical records. Our reviewer found that the enrollee was a then 83-year-old 
female with a history of chronic obstructive pulmonary disease, coronary artery disease, hypersensitivity lung 
disease, and hypertension who was evaluated in the emergency department on December 21, 2021 for a 
laceration on the right eyebrow. She was evaluated with a physical exam, x-ray studies and laceration repair. 
The review indicates that there was no decision making of high complexity. The review has determined that the 
use of code 99285 was not supported by the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285, an 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285, an 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 provided on December 12, 2021.