Policy No: 110
Date of Origin: 09/01/2020
Section: Facility
Last Reviewed: 07/01/2024
Last Revised: 07/01/2024
Approved: 07/01/2024
Effective: 11/01/2024
Policy Applies to: Group and Individual & Medicare Advantage

This policy applies to outpatient facilities.

Straightforward - The presented problem(s) are typically self-limited or minor conditions with no medications or home treatment required.

Low - The presented problem(s) are of low to moderate severity.

Moderate - The presented problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

High - The presented problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

Emergency Department -

• Type A emergency department: must meet regulatory requirements and be open 24 hours/day and 7 days/week and apply codes 99281-99285.

• Type B emergency department: must meet regulatory requirements but is not open 24 hours/day and 7 days/week and apply codes G0380-G0384.

Emergency Medical Condition -

• Health of member or their unborn child is serious, or
• Has serious body function impairment, or

• Has serious dysfunction of any bodily organ or part.

Emergency Service - Services needed to stabilize an emergency medical condition.

Background - Currently, there are no national standards, that assign levels of services in the emergency department (ED).

The American College of Emergency Physicians (ACEP) has developed ED level guidelines which are in line with the outpatient prospective payment system (OPPS) principles. The level of care is determined by interventions/complexity of service.

Optum has developed the Emergency Department Claim (EDC) Analyzer, which is based on the 11 general guidelines for coding outpatient facility levels published by the Centers for Medicare and Medicaid Services (CMS).

Individual facility provisions, contracts or state or federal guidelines take precedence over this policy.

This reimbursement policy focuses on outpatient facility ED claims that are submitted with level 1 (99281/G0380), level 2 (99282/G0381), level 3 (99283/G0382), level 4 (99284/G0383), and level 5 (99285/G0384).

Interventions/Complexity of Service

Reimbursement for facility ED services are based on the highest-level E&M and revenue code for which a claim qualifies. A CPT or HCPCS code for E&M must be billed, based on the complexity of facility intervention(s) that occurred, during the patient ED visit.

Our health plan requires documentation from the ED visit that includes but is not limited to physician order(s), presenting symptoms, diagnoses, and treatment plan in the medical record.

Our health plan reviews the complexity level of facility interventions for the E&M codes as described by ACEP. Each level provides facility intervention examples that align with the E&M service.

Exceptions include:

• ED visits resulting in observation status or inpatient admission. ED visits that result in an Inpatient submission will follow guidelines under FAC103 Reimbursement of Facility Room and Board policy.
• Trauma or critical care services.
• Surgical intensive care services.

CMS Coding Principles
CMS requires each facility to establish its own facility billing guidelines. The CMS Outpatient Prospective Payment System (OPPS) lists eleven criteria that must be met for facility coding guidelines.

The guidelines are:

• Follow the intent of the associated CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
• Be based on hospital facility resources versus physician resources.
• Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
• Meet HIPAA requirements.
• Only require documentation that is clinically necessary for patient care.
• Not facilitate upcoding and gaming.
• Be in writing, or recorded, well-documented and provide the basis for selection of a specific code.
• Be applied consistently across patients in the clinic or ED to which they apply.
• Not changed with great frequency.
• Be readily available for fiscal intermediary review.
• Result in coding decisions that could be verified by other hospital staff, as well as outside sources.

Claims may be identified for one of the following types of reviews:

Clinical Review
Our health plan reviews the complexity level of facility interventions for the E&M codes as described by ACEP. Each level provides facility intervention examples that align with the E&M service.

Coding Review
Our health plan utilizes the Optum EDC Analyzer tool to determine the ED level to be reimbursed for certain facility claims. There are several factors taken into account to determine the calculated E&M visit coding levels. Those factors are:

• Presenting problems – as defined by the ICD-10 reason for the visit (RFV) diagnosis.
• Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e. Lab, X-ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound).

• Member complexity and co-morbidity – based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary, and external cause of injury diagnosis codes.

EDC Analyzer Exceptions Include:

• Members less than 2 years of age.
• Members admitted to the hospital as inpatient.
• Members who have expired in the ED.

If a member is admitted as an inpatient from the ED or from observation following a visit to the ED, the ED services provided to that member must be submitted on the same claim as the inpatient services and are not subject to this policy.

American College of Emergency Physicians (ACEP), ED Facility Level Coding Guidelines

Centers for Medicare and Medicaid Services (CMS), 42 CFR § 422.113

Centers for Medicare and Medicaid Services (CMS), OPPS Visit Codes Frequently Asked Questions, CMS.gov

Optum EDC Analyzer (PDF)

Correct Coding Guidelines

Reimbursement of Facility Room and Board