Emergency Department Coding Review

Policy Notice

If this policy conflicts with a member benefit document or provider agreement, the governing document will control. Providers must submit complete and accurate claims supported by documentation and coded in accordance with HIPAA-approved code sets and applicable coding requirements.

This policy is not intended to direct or instruct provider billing practices but to describe the methodology used for claim review.

Purpose

This policy describes BCBSNE’s approach to reviewing certain emergency department (ED) facility claims to determine whether the billed level of service reasonably reflects the intensity of hospital resources reported on the claim.

It is intended to promote consistency and alignment between reported services and billed ED levels while minimizing variation unrelated to actual resource utilization.

Application

This policy applies to facility emergency department claims submitted on the UB-04 claim form or its electronic equivalent and billed with CPT codes 99284 or 99285 (or applicable HCPCS equivalents), when the member:

• Is treated and released from the emergency department
• Is not admitted, transferred, or placed in observation

This policy applies to participating and nonparticipating facilities unless otherwise specified by provider agreement.

Policy Statement

Emergency department facility coding is expected to reflect the overall intensity of hospital resources utilized during the encounter.  BCBSNE recognizes that hospitals may maintain facility-specific emergency department leveling methodologies that comply with applicable CMS requirements and industry standards. Differences in facility resource assignment methodologies alone do not constitute a basis for claim adjustment.

The appropriate level of service is determined based on the totality of services reported on the claim, including, but not limited to:

• Diagnoses reported
• Procedures and interventions
• Diagnostic testing and imaging
• Medications administered
• Monitoring and reassessment
• Care coordination activities

No single service, diagnosis, test, or intervention—alone or in combination—establishes or guarantees a specific level of service.

Facility coding must be based on hospital resource utilization and not on physician work alone.

Claim Review Methodology

Initial Review

The initial review is based solely on the submitted claim. Medical records are not routinely reviewed at this stage.

The review evaluates:

• The internal consistency of the claim
• The scale and intensity of services reported
• The relationship between diagnoses, procedures, and ancillary services
• The overall claim profile in its entirety

The determination is made holistically, rather than by the presence or absence of specific individual services.

Use of Additional Information

BCBSNE may request and review medical records or additional documentation, particularly on reconsideration or appeal or when additional validation of resource utilization is necessary. When reviewed, this may include:

• Nursing and clinical documentation
• Monitoring activities
• Care coordination
• Safety interventions
• Other facility resources not fully reflected on the claim.
• When additional validation of resource utilization is necessary

General Leveling Principles

Emergency department levels reflect increasing intensity of facility resource utilization, not specific service combinations.

• Moderate to high resource utilization may be consistent with Level 4
• Very high resource utilization and complexity may be consistent with Level 5

The distinction between levels is based on overall encounter intensity, not discrete events or isolated services.

Illustrative Resource Considerations

The following categories represent types of resources that may be considered during review. These are not requirements, thresholds, or criteria and are not determinative of any level.

Diagnostic Evaluation

• Use of Point of Care (POC) samples, diagnostic testing, imaging such as CT, U/S, MRI, x-rays or repeated studies
• Genitourinary, pelvic, rectal examinations
• Venipunctures with specimen collection
• Urinalysis, pregnancy urine testing
• Combination of tests reflecting increasing complexity

Therapeutic Interventions

• Administration of medications and Intravenous fluids requiring monitoring
• Application of assistive devices, such as ace wraps, splints, casting, DME
• Wound care and dressing care
• Nebulizer treatments
• Catheter insertions
• Delivery of treatments involving nursing or technical support
• Blood product use
• Sedation for treatment

Monitoring and Reassessment

• Frequency and intensity of reassessment
• Specialized vital signs such as neuro checks, orthostatic, coma and or trauma scale
• Ongoing monitoring based on clinical presentation such as continuous cardiac monitoring, oxygen use

Procedural and Support Services

• Assistance with or preparation for procedures such as lacerations
• Use of specialized equipment or staff resources
• Isolation procedures
• Care of special needs or child age 13 and under

Behavioral Health and Safety Services

• Observation, intervention, or coordination for behavioral health presentations
• One-on-one custodian care such as a sitter
• Safety-related interventions or additional staff resources

Care Coordination

• Coordination with external providers or services such social services
• Use of interpretation services
• Use of hospital staff outside of ED staff such as OR and Labor and delivery staff
• Disposition planning requiring additional facility resources

Important Clarifications

• The examples above are illustrative only and are not intended to define billing thresholds or standards
• The presence or absence of any individual service does not determine the level of care
• Similar services may correspond to different levels depending on overall resource intensity and clinical context
• Billing practices should reflect actual resource use and should not be structured to meet specific examples or elements

Exclusions and Additional Considerations

• Critical care services are not addressed by this policy and should be billed separately when appropriate
• Observation services, when separately reportable, are not determinative of ED level
• Continued monitoring after the ED evaluation does not independently support a higher ED level
• Services needed to maintain accreditation (i.e., facility issues, supervision, technology support)
• Generic services not related to the specific individualized needs of the patient (i.e., housekeeping, securing possessions)
• Administrative services such as registration
• Triage and discharge instructions

Billing Pattern Monitoring

BCBSNE may evaluate provider billing patterns across emergency department claims. Benchmarking data may be used to identify claims or providers for further review but will not, in itself, determine the appropriate level of service for an individual claim. Individual claim determinations will be based on the services reported and any applicable supporting documentation.

Patterns that demonstrate:

• Disproportionate use of higher-level ED codes
• Inconsistency between billed levels and overall claim intensity
• Variation from expected peer or regional benchmarks may be subject to additional review, adjustment, or audit.

Claim Review Outcome

If the billed level of service is not supported by the overall claim profile, the level may be adjusted to the code most consistent with the reported services.

The goal of this review is to align the billed code with the level of resource utilization supported by the claim.

References

This policy is informed by generally accepted coding principles and industry guidance, including resources from:

• Centers for Medicare & Medicaid Services (CMS)
• American College of Emergency Physicians (ACEP)
• American Medical Association (AMA)