Payment Policy: Leveling of Emergency Room Services
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Defines the health plan's reimbursement practice of reducing payment for billed Level 4 or 5 ED E/M services to Level 3 when the discharge diagnosis indicates lower complexity or severity; applies to hospitals, free-standing emergency centers, physicians and other qualified health professionals billing Arizona Complete Health.
No material clinical or coverage changes in this revision.
Reimbursement Leveling Rules
Leveling reimbursement criteria
Reimbursement adjudication rules when billed ED service level exceeds diagnosis-indicated severity:
ED E/M Codes and Diagnosis Thresholds
| 99281 | Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional. |
| 99282 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. |
| 99283 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. |
| 99284 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.. |
| 99285 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making |
Appeals, Documentation & Billing Requirements
Appeals and documentation: appeal right and primary discharge diagnosis must be first
Providers may appeal the plan's adjudication if they disagree with how a claim was processed. When submitting appeals, include supporting clinical documentation that demonstrates the diagnosis and level of service. Additionally, ensure the patient's primary discharge diagnosis is reported in the first diagnosis position on the emergency room claim form, as the plan uses that diagnosis to adjudicate ED service level against its algorithm.
- Provider may appeal if they disagree with how the claim was adjudicated.
- Include clinical documentation that supports the billed ED level when appealing.
- Bill the patient's primary discharge diagnosis in the first diagnosis position on the ED claim form.
Key Definitions
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