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CPT Codes 99281-99285 Emergency Department Visits
Last updated Jan 15 2018
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CMS has authorized WPS Government Health Administrators (GHA) to conduct the Targeted Probe and Educate (TPE) review process. This is a required process for providers identified by Medical Review.  If your facility is chosen, a WPS Nurse Analyst will contact you to facilitate the process. Once reviews begin, you will be notified of the selected claims per your normal Additional Documentation Request (ADR) process. This may be via a mailed ADR letter and/or Direct Data Entry (DDE). Providers will then have 45 days to submit medical record information that supports the services billed. Before you send the requested records, GHA suggests a clinician double-check the accuracy of your submitted claim.
 
Documentation Guidance for a Successful Review of CPT Code 99281-99285 - Emergency department visit for evaluation and management of a patient

  • Emergency Room Visit note, along with documentation of any labs, tests in the radiologic section of the CPT or medicine section of the CPT Code book that may have been performed during the ER visit;
  • Documentation of medications administered during the ER visit;
  • Attestation statement (if physician signature on ER note is illegible, stamped or the electronic signature is missing)

Review of Documentation

WPS GHA staff will review the claim documentation after its receipt, according to CMS timelines, and will determine whether or not the submitted documentation meets the requirements. Along with the claim determination, WPS GHA staff will make a determination of liability for services and whether you are without fault for overpayments. Individual claim result letters will be available via the WPS GHA Portal. General results of the CPT Code 99281-99285 Emergency department visit for evaluation and management of a patient review will be posted to the WPS GHA website following completion of the review process. If you have any questions, contact the Provider Contact Center.

Resources: 

Internet Only Manual (IOM) 100-04, Chapter 12 PDF Icon
Section 30.6.1, Subject: Selection of Level of Evaluation and Management Service 

The Evaluation and Management Services Guide PDF Icon

Internet Only Manual (IOM) 100-04, Chapter 12 PDF Icon Section 30.6.1 (B), Subject: Split Shared Services 

The 1995 Documentation Guidelines for Evaluation and Management Services PDF Icon

The 1997 Documentation Guidelines for Evaluation and Management Services PDF Icon

Internet Only Manual (IOM) 100-04, Chapter 12 PDF Icon Section 100 – Teaching Physicians  

Current Procedural Terminology (CPT) Manual, Professional Edition, (CPT codes 99281-99285)

Additional Resources:

Targeted Probe and Educate

Medical Review Calculator

PWK

Use the WPS GHA Portal to Submit Documentation

CMS Internet-Only Manual (IOM) 100-08, Chapter 3 PDF Icon

WPS GHA Provider Outreach and Education offers three types of events for live training, these include: in person seminars, topic-driven teleconferences and webinars presented live online.  Visit the WPS GHA Learning Center to register for any of our live events.

WPS GHA also offers On Demand education that you can view anytime at your convenience.  The On Demand features include quick system and billing tutorials as well as audio recordings of teleconferences.  You can view the On Demand education anytime by visiting the WPS GHA Learning Center