Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 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 (CPT 99285) provided on January 4, 2023.  
 You asked the Plan to pay for 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 (CPT 99285) provided on January 4, 2023. You say that the services were billed 
with the correct CPT code based on the provided medical records. The Plan denied your request. The Plan says 
the appropriate CPT code is 99284. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and 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 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 (CPT 99285) provided on 
January 4, 2023.  Our reviewer says that the documentation does not support the billed CPT code 99285. Our 
reviewer found that the enrollee has a medical history including hypertension and end-stage renal disease 
requiring hemodialysis who presented to the emergency department after a fall resulted in right hip pain. The 
enrollee was diagnosed with a right femur fracture and admitted to the hospital for further management. At the 
time of presentation, the enrollee was hemodynamically stable. The plan of care included specialty 
consultation. In this case, the documentation does not support the CPT code 99285. The documentation 
available for review does not support that the presenting problems were of high severity or that the medical 
decision was of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 (CPT 99285) provided on January 4, 2023 have not been met. Therefore, we 
decided that the Plan does not have to pay for 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 (CPT 99285) provided on January 4, 2023.