CurrentBlue Cross Blue Shield - NevadaPolicy C-13001

Emergency Department: Leveling of Evaluation and Management Services (Facility)

Defines how the Health Plan classifies and reimburses facility Emergency Department (ED) Evaluation and Management (EIM) code levels for emergent ED services and outlines adjustments, denials, and recoupment actions; applies to facility claims submitted to Blue Cross Blue Shield - Nevada unless contract or state-specific exemptions apply.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyEmergency Department: Leveling of Evaluation and Management Services (Facility)

Policy CodePolicy C-13001

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionIf the EIM code level billed is higher than supported by claim documentation, the plan may adjust reimbursement to the lower level, deny and request resubmission or documentation, or recover overpayments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 pagesdocument length

3explicit exclusions to leveling

10/23/2024most recent review

Emergency Department (ED) Facility Evaluation & Management - Coverage Criteria

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The Health Plan reimburses facility emergent ED services based on its classification of ED Evaluation and Management (EIM) code levels determined by facility interventions/resources and the intensity and/or complexity of services reported on the claim.

If the EIM code level billed is higher than supported by the claim

Adjust reimbursement to reflect the lower ED EIM classification.
Deny the claim and request resubmission at the appropriate level or request documentation supporting the level billed.
Recover and/or recoup monies paid in excess of the EIM code level supported on the claim.

Exclusions (policy does not apply)

Member expired in the ED.
Critical care or outpatient surgery performed during the ED visit.
Member admitted inpatient or transferred to another facility.

Providers must use appropriate HIPAA-compliant CPT, HCPCS or revenue codes and ensure medical record documentation supports the billed ED EIM level.

Operational requirement

The Health Plan adheres to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

Regulatory adherence

Coding and Level Determination

ED EIM coding requirementsmixed

CPT/HCPCS (ED E/M codes)

Facility ED Evaluation and Management codes; providers must utilize appropriate HIPAA-compliant CPT, HCPCS and/or revenue codes supported by medical record documentation.

Level support threshold

Policy action when submitted EIM level exceeds documentationIf the EIM code level submitted is higher than the level supported on the claim, the Health Plan may adjust reimbursement to the lower ED EIM classification, deny the claim and request resubmission at the appropriate level or request documentation supporting the level billed, or recover/recoup monies paid in excess.

Possible reimbursement adjustmentAdjust reimbursement to reflect the lower ED EIM classification when documentation does not support the billed level.

Denial and resubmissionDeny the claim and request resubmission at the appropriate level or ask the provider to submit documentation supporting the level billed.

Recovery/recoupmentRecover and/or recoup monies previously paid in excess of the EIM code level supported by the claim.

Billing, Documentation, and Reimbursement Adjustments

Denial Risk

Reimbursement adjustments, documentation requests, and potential recoupment for unsupported ED EIM levels

If the ED EIM code level billed is higher than the level supported by the claim, the Health Plan may adjust reimbursement to the lower ED EIM classification, deny the claim and request resubmission at the appropriate level or request documentation supporting the level billed, or recover/recoup monies paid in excess.

Health Plan may adjust reimbursement to the lower ED EIM classification.
Health Plan may deny the claim and request resubmission at the appropriate level or request documentation supporting the level billed.
Health Plan may recover and/or recoup monies previously paid in excess of the supported EIM level.

Key Definitions

Interventions

DefinitionInterventions — The staff the facility utilizes and their work performed; professional provider services are not considered facility interventions or resources.

Facility staffing examplesIncludes nursing, technicians, and other facility-employed personnel involved in delivering services during the ED encounter.

Scope of workCovers the tasks and activities performed by facility staff to furnish services indicated on the claim.

Resources

DefinitionResources — Facility building, equipment and/or supplies utilized.

Physical infrastructureIncludes the facility building space used to deliver ED services.

Equipment and suppliesIncludes medical equipment and consumable supplies used during the ED encounter as reported on the claim.

Intensity and/or Complexity

DefinitionIntensity and/or Complexity — 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.

Components consideredConsiders number and specialization of staff, degree of equipment/supply use, and diagnostic services performed.

Clinical factorsIncludes presenting problem severity, member age and acuity that influence level classification.

Emergency Services

DefinitionEmergency Services — A medical condition manifesting by acute symptoms of recent onset and sufficient severity that absence of immediate medical care could result in serious jeopardy, impairment, dysfunction, or disfigurement (including severe pain); for a pregnant woman, serious jeopardy to her or her unborn child.

Onset and severityRequires recent onset of acute symptoms with sufficient severity to warrant immediate medical attention.

Potential consequencesWithout prompt care could result in serious jeopardy to health, serious impairment of bodily function, serious dysfunction of an organ or part, or serious disfigurement.

Policy Revision History

2024-10-23policy_reviewLatest

Review approved (Last Approval Date 10/23/2024); effective updates include market-specific exemption changes noted for Colorado, Maine, and New Hampshire.

2024-02-16content_update

Updated descriptions to reflect EncoderPro 2023 terminology and coding descriptions.

2021-09-01update

Policy updated (entry noted 09/01/2021) as part of ongoing revisions to align coding and definitions.

2020-06-26review

Review approved with updates to Coding and Definitions sections and policy name changes; multiple state effective dates applied beginning 01/01/2021 and 04/01/2021 for some states.

2019-06-01review

Review approved; updated policy template and relocated Description content into Definitions section.

2018-04-06review

Review approved; language updated to remove references to professional services and maintain exhibit references.

2013-02-22initial_approval

Initial approval (02/22/2013) with effective date 06/01/2013 establishing the policy.