Emergency Department: Leveling of Evaluation and Management Services - Facility
Defines how the health plan classifies and reimburses facility Emergency Department E/M service levels for commercial claims and actions the plan may take when billed levels exceed those supported by the claim; applies to facility ED services except where contracts or market-specific exemptions apply.
No material clinical or coverage changes in this revision.
Coverage Criteria for ED Facility E/M Services
ED facility E/M reimbursement criteria
Covered when ALL of the following are met:
ALL of the following
- The encounter is for Emergency Services (acute symptoms of recent onset with sufficient severity that a prudent layperson could reasonably expect lack of immediate care to result in serious jeopardy, impairment, dysfunction, disfigurement, or risk to a pregnant woman or her unborn child).
- The facility documents emergent care and the claim reflects services provided during an ED encounter.
- The level of ED E/M billed is supported by the facility’s documented classification of the intensity and/or complexity of resources and/or interventions utilized to furnish all services indicated on the claim (facility building, equipment, supplies, and facility resources; professional services are not considered facility interventions).
AND the plan may do ONE of the following when billed level exceeds support:
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