CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Emergency Department Facility Level Coding and SIU Review

Defines Anthem/Blue Cross Blue Shield Nevada's post-pay and prepayment review process to validate facility emergency department encounter level (ED E&M) based on interventions, resources, intensity/complexity, and lists clinical examples by CPT/HCPCS ED facility levels; affects facility billing and coding for ED claims.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyEmergency Department Facility Level Coding and SIU Review

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAnthem may perform post-pay and prepayment review to validate the appropriate facility ED level for claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5facility ED E&M levels described

Post-pay/prepayclaim review workflows used

Interventions/resourcesprimary determinants

Apr 14, 2022document revision

Emergency Department Facility Level Determination

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ED facility level determination and review

Facility ED level is determined by the highest intervention/resource and intensity/complexity demonstrated on the claim; Anthem may perform prepayment or post‑pay review and refer undetermined cases to a Medical Director.

Anthem may perform post‑pay or prepayment review to validate the appropriate facility emergency department encounter level.

The level of ED E&M (facility) is identified by the intensity and/or complexity of resources or interventions the facility documents on the claim.

Providers must submit appropriate HIPAA‑compliant codes for all services rendered during the ED encounter; the highest intervention/resource used on the claim determines the final facility ED level.

If a determination cannot be made based on the guidance in this document, the case will be referred to a Medical Director for determination.

ED Facility E&M Codes and Determination Rule

ED facility E&M codesCPTCovered

99281	Straightforward/Triage only (facility level corresponding to G0380)
99283	Moderate complexity (facility level corresponding to G0382)
99284	Moderate-high complexity (facility level corresponding to G0383)
99285	High complexity (facility level corresponding to G0384)
G0380	Facility ED level - Straightforward
G0382	Facility ED level - Moderate complexity
G0383	Facility ED level - Moderate-high complexity
G0384	Facility ED level - High complexity

Determination rule

Determination ruleThe highest intervention or resource used during the ED encounter determines the final facility ED level; assessment is based on intensity/complexity, member age, acuity, and diagnostic services on the claim.

Review methodsAnthem may perform post-pay and prepayment review to validate the appropriate ED facility level.

Coding requirementProviders must utilize appropriate HIPAA-compliant codes for all services rendered during the ED encounter.

Review Processes and Provider Implications

Denial Risk

SIU review: post‑pay and prepayment validation and documentation risk

Anthem may perform post‑pay and prepayment reviews to validate the assigned facility ED level and may request supporting documentation; providers must bill using appropriate HIPAA-compliant codes and be aware that the highest intervention/resource on the claim determines the final facility ED level.

Anthem utilizes post-pay and prepayment review in certain circumstances to validate the appropriate level for facility emergency department claims.
Providers must utilize appropriate HIPAA compliant codes for all services rendered during the ED encounter.
The highest intervention/resource used will determine the final facility ED level.

Definitions: Interventions, Resources, Intensity/Complexity, Emergency Services

Interventions — definition

Interventions (term)The staff the facility utilizes, and their work performed.

Examples (context)Direct clinical actions performed by facility personnel during the ED encounter as indicated on the claim.

ExclusionProfessional provider services are not considered facility interventions for facility-level determination.

Interventions — staff and their work

Facility staff roleInterventions refer to the staff the facility utilizes and the work they perform during the ED encounter.

Work performedIncludes the clinical activities and tasks performed by facility personnel that are billed on the claim.

Relation to codingIntervention details on the claim are used to determine facility ED level by intensity/complexity.

Resources — definition

Resources (term)Facility building, equipment and/or supplies utilized.

ScopeIncludes physical plant, medical devices, and supplies documented on the claim used to deliver ED services.

UsageResources reported on the claim contribute to assessment of intensity/complexity for facility level determination.

Resources — facility items and exclusions

Facility itemsFacility building, equipment and supplies utilized during the ED encounter.

Exclusion of professional servicesProfessional provider services are not considered facility interventions or resources.

Role in determinationFacility resources documented on the claim are evaluated (along with interventions) to determine ED facility level.

Intensity and/or Complexity — definition

Intensity/Complexity (term)Quantity, type or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity and diagnostic services performed, as indicated on the claim.

DeterminantUsed to identify the appropriate ED facility level based on resources and interventions documented.

Factors consideredIncludes member age, acuity, presenting problem severity, and diagnostic services rendered.

Intensity/Complexity — factors informing ED level

Elements informing levelQuantity, type or specialization of interventions/resources used plus member factors (age, acuity) and diagnostic services documented on the claim.

ApplicationIntensity/complexity assessment of interventions and resources determines the facility ED E&M level during review.

OutcomeThe combined assessment of these elements may prompt referral to a Medical Director if determination cannot be made from guidance.

Emergency Services — Prudent layperson standard

Prudent layperson standardEmergency Services are conditions with acute symptoms of recent onset and sufficient severity that a prudent layperson with average health knowledge could reasonably expect that absence of immediate medical care could result in serious jeopardy, impairment, dysfunction, disfigurement, or jeopardy in pregnancy.

ScopeDefines when an ED visit qualifies as emergency services for purposes of review and coverage considerations.

Standard basisFocuses on the reasonable expectations of an average person rather than clinical hindsight.

Emergency Services — acute symptoms definition

Acute severe symptomsA medical condition manifesting by acute symptoms of recent onset and sufficient severity (including severe pain) so that a prudent layperson could reasonably expect the absence of immediate care to result in serious jeopardy, serious impairment, dysfunction, disfigurement, or pregnancy-related jeopardy.

Examples of consequencesSerious jeopardy to health, serious impairment to bodily function, serious dysfunction of any organ, serious disfigurement, or jeopardy to pregnant woman or unborn child.

Use in reviewThis definition guides whether care rendered should be treated as Emergency Services during ED level determination and claim review.