Emergency Medicine – Compliance Basics

Emergency Medicine has some unique compliance risks because of high volume, frequent use of APPs and residents, rapid documentation workflows, and the heavy reliance on MDM under the 2023 E/M guidelines.

Compliance Risk

These six categories will likely identify the majority of coding and compliance risk in a modern Emergency Medicine practice.

E/M Level Accuracy (99282-99285)

For education purposes, coders and providers should understand that the level selected is based upon the 2023 ED E/M guidelines, which focus on:

Unlike office visits, the ED code level is determined by Medical Decision Making (MDM) only. There is no time option for 99281-99285.

Because accurate E/M code selection ultimately depends on a thorough understanding of Medical Decision Making, I have included links to several internal educational resources defining the requirements for each MDM level. Also included is the ACEP Emergency Department E/M Level Guidance, which is used internally with written permission and serves as a valuable reference for Emergency Medicine providers.

Medical Decision-Making 101 (Internal Link Only)

ACEP Emergency Department E/M Levels (external link) (Internal Link Only)

Teaching Physician Rules

Although the Emergency Department has its own unique workflow and patient population, the fundamental rules governing E/M services remain the same. This includes documentation and billing requirements for minor procedures, diagnostic and therapeutic interventions, and interpretation services. To avoid duplicating information already available, I have included links to our internal Teaching Physician resources for a more in-depth review of these topics.

Teaching Physician Rules – The Basics

APP/Split-Shared Billing

No Emergency Department billing guide would be complete without addressing Advance Practice Provider (APP) split/shared services. Although APPs, residents, and attending physicians frequently work together in a highly collaborative environment, the billing rules applicable to each provider type are fundamentally different.

Residents are not independently billable providers. Services involving resident participation must meet teaching physician requirements for the attending physician to report the service.

APPs, however, are credentialed billing practitioners who may bill directly for the care they provide.  When specific split/shared billing requirements are met, CMS permits the supervising physician to report the service.

Given the complexity of this topic and the importance of understanding the distinctions, I have included links to our internal Advance Practice Provider resources.

Critical Care (99291-99292)

Critical care remains one of the most challenging coding concepts for providers to master. Successful reporting requires more than documenting a seriously ill patient. The record must support the presence of a critical illness or injury with a high probability of imminent or life-threatening deterioration, demonstrate the physician’s active management to prevent or address that deterioration, and include more than 30 minutes of qualifying critical care time.

When these requirements are not met, report the appropriate Emergency Department E/M code or other applicable evaluation and management service.

Independent Interpretation & Discussion Credits

Emergency Medicine physicians often count ECGs, CTs, X-rays, Ultrasounds, etc. towards MDM. The problem is documentation.

Example 

Not enough:  “ECG reviewed.”

Better: “I independently interpreted ECG showing normal sinus rhythm at rate 72, no acute ST-T changes.”

Documentation should clearly reflect an independent interpretation contributing to MDM.

Similarly, discussion with external providers is another common source of unsupported credit. Documentation frequently says something like “discussed with hospitalist” or “spoke with cardiology.”

Recommended documentation:

• Who was contacted?
• Why they were contacted
• Outcome of consultation?
• Effect on management?

The discussion can only support MDM if documented adequately.

Modifier -25

Modifier -25 is a frequent audit focus in Emergency Medicine. Reporting an E/M service on the same date as a minor procedure requires documentation supporting a significant, separately identifiable evaluation and management service above and beyond the work normally associated with the procedure.

A simple laceration repair, where the evaluation is limited to determining the need for and performing the repair, will generally not support a separate E/M service. However, when the encounter involves a broader assessment, such as evaluation of head trauma, neurologic examination, diagnostic imaging interpretation or review, and medical decision making related to additional injuries or conditions, a separately identifiable E/M service may be appropriate.

In these situations, the documentation should clearly demonstrate that the E/M service addressed issues extending beyond the procedural work itself.

Cloned Documentation/Template Reliance

Emergency Department notes often contain templated risk statements such as, “Risk of sudden decompensation, disability, organ failure, permanent morbidity, or death.” While sometimes appropriate, generic language used repeatedly across encounters can weaken medical necessity and raise concerns about cloned documentation.

Medical necessity is patient-specific. The record should explain why this patient required the evaluation and management provided and reflect the physician’s individualized clinical reasoning. For additional discussion, see Why Clear Clinical Notes Matter.

Artificial intelligence is simply the newest documentation tool. Like templates, copy/paste, and copy-forward functionality, it can improve efficiency when used appropriately. However, providers remain responsible for reviewing, editing, and personalizing the record to ensure it accurately reflects the care provided, clinical reasoning, and medical necessity of the service reported. Technology should assist documentation, not replace the provider’s clinical voice.

Introducing the AI Scribe

Beyond the Template

Accurate coding begins with accurate documentation. When the medical record clearly reflects the patient’s condition, the physician’s decision making, and the medical necessity of the services provided, code selection often follows naturally.