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.

Telemedicine/Telephone Services for Commercial Products and Medicare Advantage Plans

Modifier GT was added to the policy to be used by practitioners billing telehealth services under the CAH (Critical Access Hospital) Optional Payment Method II. For additional details related to this policy, please click here.