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.