CPT code 99284: What is it & When should I use it?

When it comes to emergency-department billing, few codes create as much second-guessing as CPT code 99284. Providers and coders alike often struggle to document the “moderate complexity” that this code requires, leaving charts vulnerable to audits and reimbursement delays. Without precise documentation, even a legitimately billed 99284 encounter can be downgraded—or worse, denied—costing your practice valuable time and revenue.

This comprehensive guide walks you through everything you need to know about CPT code 99284: what it represents, when it applies, the documentation payers expect, and how to avoid the costly mistakes that keep claims from being paid promptly.

What CPT Code 99284 Represents

CPT code 99284 is one of the five levels of emergency department (ED) evaluation and management (E/M) services defined by the American Medical Association (AMA).
It is used for ED visits that require the following:

• Comprehensive history and comprehensive examination
  
• Medical decision making of moderate complexity
  

Unlike other E/M codes, ED visit codes don’t require that the patient be new or established. They are based entirely on the key components of history, exam, and medical decision making (MDM).

Typical clinical scenarios for 99284 might include:

• Moderate asthma exacerbation requiring multiple nebulizer treatments and close monitoring
  
• Abdominal pain with potential appendicitis needing imaging and serial exams
  
• Complicated laceration repair with risk of infection or foreign body
  

In short, 99284 is for patients whose conditions are serious enough to require thorough evaluation and moderate-complexity decision making, but not critical-care-level intervention.

Why Documentation Is Everything

Reimbursement for 99284 encounters hinges on proving medical necessity and MDM complexity.
Common documentation pitfalls include:

• Incomplete history or exam – Missing review of systems or physical-exam elements can downgrade the visit to 99283.
  
• Vague medical decision making – Payers need evidence of data review, differential diagnoses, and management options considered.
  
• Unclear physician involvement – Failure to document attending physician participation can trigger denials.
  

Because ED services are high volume and high cost, these claims are frequent targets for audits by Medicare and commercial payers. One insufficient note can lead to recoupments that add up across multiple visits.

Key Elements Payers Look For

To confidently bill CPT code 99284, ensure the following are clearly documented:

1. Comprehensive History
   
   • Chief complaint, extended HPI (4+ elements), complete review of systems (10+), and past/family/social history.
     
2. Comprehensive Examination
   
   • Eight or more organ systems or a complete exam appropriate to the presenting problem.
     
3. Moderate MDM
   
   • Multiple possible diagnoses or management options
     
   • Moderate amount/complexity of data reviewed (labs, imaging, consultations)
     
   • Moderate risk of significant complications, morbidity, or mortality
     

Remember that time is not a key factor unless counseling or coordination of care dominates the visit.

Five Costly Mistakes to Avoid

1. Undercoding out of caution
   Providers sometimes default to 99283 to avoid scrutiny. Over time, this leaves significant legitimate revenue unbilled.
   
2. Missing decision-making details
   A note that simply states “labs reviewed” without summarizing findings and impact on treatment may not meet moderate-complexity requirements.
   
3. Template traps
   Over-reliance on EHR templates can result in cloned documentation that doesn’t match the specific encounter, a red flag for auditors.
   
4. Poor handoff documentation
   When multiple clinicians are involved, unclear handoffs or lack of a final attending note can invalidate the claim.
   
5. Late or incomplete signatures
   Claims can be denied if documentation is missing a timely physician signature or authentication.
   

Best Practices for Flawless 99284 Documentation

• Capture thought process in real time. Use dictation or point-of-care notes to describe differential diagnoses and rationale for tests.
  
• Audit internally. Conduct periodic self-audits or partner with a billing service to review random charts for compliance.
  
• Educate your team. Coders, scribes, and physicians should all understand the components of moderate MDM and what payers expect.
  
• Leverage billing experts. A professional billing service can identify gaps, train staff, and reduce denial rates.
  

How Professional Billing Support Makes the Difference

Even experienced ED teams benefit from an outside review. A dedicated medical billing service can:

• Perform ongoing compliance checks to catch documentation issues before claims go out
  
• Optimize coding for accurate reimbursement while reducing audit risk
  
• Provide feedback and education to physicians and coders
  
• Track denial trends and appeal quickly to protect revenue
  

At Billing Service Quotes, we connect healthcare providers with vetted billing companies that specialize in emergency-department coding and compliance. Whether you need a full-service partner or targeted audit support, our network can help you safeguard revenue and stay compliant with the latest payer guidelines.

Final Thoughts

CPT code 99284 captures a critical segment of emergency care—cases that demand comprehensive evaluation and moderate complexity without crossing into critical care.
The difference between a clean, paid claim and a costly denial often comes down to meticulous documentation and correct coding.

If you want to speed this process up and reduce audit risk, get in touch with our team at Billing Service Quotes. We’ll match you with a trusted billing partner who can help you master 99284 documentation, prevent denials, and keep your revenue cycle running smoothly.