assignment of e/m levels emergency room


The hospital must assign Emergency Room Evaluation and Management codes (E/M) codes for all ER visits. The E/M code is billed in Revenue Code 450 –Emergency Room on the UB-04.

Below are a few of the items we see when reviewing Emergency Room records and levels:

  • Hospital approved ER criteria not applied correctly, and the incorrect E/M level is assigned which results in over coding or under coding
  • Incorrect points assigned and therefore the wrong E/M level is billed; many facilities use a point system to assign levels of care based on the services rendered
  • Incorrect E/M level assigned from the computer-generated ER criteria software
  • Documentation/services do not substantiate the E/M level assigned
  • ER Criteria outlines that a level 5 visit (99285) is automatically assigned if the patient is admitted to the hospital or transferred even if the documentation/services provided do not justify a level 5
  • The discharge status code billed does not substantiate the E/M level assigned (i.e., discharge status 01 to home and E/M level 5 assigned)

We recommend all facilities have an ER matrix, ER criteria, or ER acuity sheet that is used to determine the E/M level assigned for each visit rendered in the ER.

The ER matrix/criteria/acuity sheet must be applied consistently to all hospital ER visits. Suggestions for applying the ER matrix:

  1. The staff who assign the ER E/M levels must understand the criteria and the documentation required to substantiate each level
  2. Require the ER Matrix be completed for each ER visit to substantiate the E/M level assigned
  3. Implement a review process to include:
    • Confirmation that the matrix is applied properly and consistently to all claims and the correct E/M level is assigned; a Pre-bill review is recommended
    • Establish a formal process to change an assigned E/M level based on the pre-bill documentation review. Providers and HIM should be involved in establishing the process.
    • Educate the staff who assign the E/M levels and Providers if changes are made in the criteria
    • Educate the staff who assigned the E/M level when the documentation does not substantiate the E/M level assigned
    • Review the ER matrix annually and make updates to the criteria as needed

It is important to have a process in place to make sure the criteria are accurately applied, the correct E/M level is assigned, and reviews are done to assure the documentation and services substantiate the level assigned. These processes will assist in assuring you are receiving the proper payment, not under or over coding, and supporting medical necessity. if you have any questions, please contact us.


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