CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP042

Emergency Department Services Evaluation and Management (E/M) - Professional

Defines coding, documentation, and reimbursement guidance for professional providers billing Emergency Department E/M services to Blue Cross and Blue Shield of Illinois; applies to claims submitted on CMS 1500 forms.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEmergency Department Services Evaluation and Management (E/M) - Professional

Policy CodePolicy CPCP042

Change TypeAnnual Review (no material clinical changes)

Effective DateSep 24, 2024

Next Review Date

Key ActionSubmit complete medical record documentation and be prepared to provide additional documentation upon request for claim review.

SourceLink

POLICY UPDATE CHANGES

09/24/2024: Annual Review

07/21/2023: New policy.

5pages

4MDM levels

5ED E/M codes

2024-09-24effective

Coverage and Documentation Requirements

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Documentation, coding, and MDM criteria for ED E/M coverage

Coverage and reimbursement for Emergency Department (ED) E/M services are contingent on appropriate documentation and coding consistent with AMA and CMS guidelines. Claims may be reviewed and payment adjusted if documentation does not support the billed level.

Medical record documentation must indicate chief complaint, diagnoses, treatment plan, all tests and imaging, and all written orders; all clinical contents should be clearly documented and signed (including clinical notes, consultation notes, lab, pathology, and radiology testing).

Providers must report the appropriate CPT, HCPCS, NDC and applicable ICD diagnosis codes that best represent the services provided per AMA and CMS documentation guidelines; accurate coding is required for claims processing and reimbursement.

Claim submissions may be reviewed to validate site of service, level of care rendered, and the level of MDM; providers may be asked to submit medical records or itemized bills to support billed services.

ED E/M level is determined by Medical Decision Making (MDM); time is not a descriptive component for ED E/M levels; history and/or physical exam are included in the E/M CPT codes when performed and the policy does not require documentation of extent of history or exam for eligible reimbursement.

To qualify for a specific MDM level, at least 2 of the 3 MDM elements (complexity of problems, amount/complexity of data, and risk of complications/morbidity/mortality) must be met or exceeded; there are four MDM levels: straightforward, low, moderate, and high.

ED E/M Codes and MDM Components

ED E/M CPT codesCPTCovered

99281	ER visit, doctor services: Emergency Department visit for the evaluation and management of patient not requiring the presence of a physician/QHP.
99282	ER visit, doctor services: Emergency Department visit for the evaluation and management of patient, resulting in straightforward MDM.
99283	ER visit, doctor services: Emergency Department visit for the evaluation and management of patient, resulting in low level MDM.
99284	Doctor visit, ER: Emergency Department visit for the evaluation and management of patient, resulting in moderate MDM.
99285	Doctor visit, ER: Emergency Department visit for the evaluation and management of patient, resulting in a high-level MDM.

MDM components required

Rule for qualifying MDM levelTo qualify for a specific type of MDM, 2 of the 3 elements (complexity of problems, amount/complexity of data, and risk of significant complications/morbidity/mortality) must be met or exceeded.

Applicability to ED E/M codesMDM determines the Emergency Department E/M level; time is not a descriptive component for ED E/M levels.

Exclusion noteLevel of MDM does not apply to CPT code 99281.

Claims Review and Contract Precedence

Documentation Required

Claim review and documentation requests

Claims for ED E/M services may be reviewed prior to payment; upon request, providers are urged to submit additional documentation (medical records and itemized bills) to validate site of service, level of care, and services billed so the payer can determine the appropriate level of MDM and payment.

Providers must submit accurate documentation of services performed and use valid HIPAA-approved code sets and industry-standard coding guidelines.
Medical records should include chief complaint, diagnoses, treatment plan, tests/imaging, written orders, and be clearly documented and signed.
Upon request, providers are urged to submit additional documentation to support the claim.

Billing Rule

Conflict resolution precedence

If this Clinical Payment and Coding Policy conflicts with a member's plan document or a provider contract, the plan document or provider contract governs; Blue Cross and Blue Shield of Illinois retains discretion in interpreting and applying the policy within applicable plan provisions.

Plan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.
Provider contracts supersede this policy where the contract terms apply.

Key Terms and MDM Elements

Medical Decision Making (MDM)

DefinitionMedical Decision Making (MDM) is the process used to determine the Emergency Department's E/M level and is measured by specified elements described in this policy.

Role in ED E/M determinationThe Emergency Department's E/M level is determined by MDM; time is not a descriptive component for ED E/M levels.

Included documentationE/M ED visit CPT codes are inclusive of medically appropriate history and/or physical examination when performed; the policy does not require documentation of the extent of history or examination for eligible reimbursement.

MDM elements

Element 1 — Complexity of ProblemsMeasures the number and complexity of problems addressed (examples: straightforward = minimal; low = 2 or more self-limited problems; moderate = one or more chronic; high = one or more chronic with greater complexity).

Element 2 — Amount and/or Complexity of DataRefers to the amount and/or complexity of data reviewed and analyzed (ranges from minimal/none to extensive depending on tests, records, or data leading to evaluation).

Element 3 — Risk of Significant Complications, Morbidity, and/or MortalityAssesses risk from additional diagnostic testing or treatment (minimal, low, moderate, or high risk based on problem severity and required interventions).