Emergency Department (ED) Outpatient Facility Evaluation and Management (E/M) Coding Policy

As part of our continued efforts to reinforce accurate coding practices, BCBSRI is adding an Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement policy.

This policy focuses on outpatient facility ED claims that are submitted with level 1 (99281), level 2 (99282), level 3 (99283), level 4 (99284), or level 5 (99285) E/M codes. This policy was developed to address inconsistencies in coding accuracy and is based on the E/M coding principles created by the Centers for Medicare and Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT® code descriptions and reasonably relate to hospital resource use. 

This policy will apply to all facilities, including freestanding facilities, which submit ED claims with level 1, 2, 3, 4, or 5 E/M codes.

As part of the implementation of these policies and procedures, BCBSRI will begin reviewing appropriate E/M coding levels based on data from the patient’s claim including the following: 

• Patient’s presenting problem
• Diagnostic services performed during the visit
• Any patient complicating conditions

Facilities submitting claims for ED E/M codes may experience adjustments to level 1, 2, 3, 4, or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial. Facilities will have the opportunity to submit appeal requests if they believe a higher-level E/M code is justified.

Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

• Claims for patients who were admitted from the ED or transferred to another healthcare setting (skilled nursing facility, long-term care hospital, etc.)
• Claims for patients who received critical care services (99291, 99292)
• Claims for patients who are under the age of two years
• Claims with certain diagnosis codes that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
• Claims for patients who passed in the ED

Ultimately, the mutual goal of facility coding is to accurately capture ED resource utilization and align that with the E/M CPT® code description for a patient visit per CMS guidance.

For additional details related to this policy, please click here.

Mammograms and Pam Smears Mandate 

This policy was updated to reflect RI general law § 27-20-17. 

For additional details related to this policy, please click here.