CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP003

Emergency Department Services Evaluation and Management - E/M Coding - Facility Services

Governs coding and reimbursement guidance for facility emergency department (ED) evaluation and management (E/M) services billed on CMS 1500/UB04 for in-network and out-of-network facilities (Place of Service 23). Affects facility billing staff and providers submitting ED claims to BCBSNM.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEmergency Department Services Evaluation and Management - E/M Coding - Facility Services

Policy CodePolicy CPCP003

Change TypeClarifications and non‑material updates

Effective DateOct 6, 2025

Next Review DateSep 26, 2025

Key ActionSubmit revenue codes with corresponding HCPCS/CPT codes and provide medical records or itemized bills upon request to validate site of service and billed level.

SourceLink

POLICY UPDATE CHANGES

Grammatical and formatting updates; Additional Resources updated; References updated; Policy Update History updated.

6distinct facility E/M levels described

0450-0459required revenue codes examples

Excludedobservation status exclusion

Upheldplan discretion

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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Covered when the facility emergency department (ED) level billed is supported by documentation of at least one listed service rendered. The facility level of care is determined by the services actually provided and documented in the member's medical record. Services provided while a member is in observation status do not generally apply to determination of the ED facility level, except as noted in the level descriptions or by provider contract. The Plan may request medical records and itemized bills to validate site of service, level of care, and services billed.

ALL of the following

At least one (1) documented service from the Possible Services Rendered column corresponding to the CPT/HCPCS level billed must be present in the member's medical record.
Medical record must indicate presenting symptoms, diagnoses, treatment plan and a written order by the provider.
Facility ED Level mapping
- Level 1 (99281, G0380): Initial assessment; no care rendered (e.g., elopes prior to evaluation); medication refill for emergency need; work/school excuse; simple wound recheck; immunization only; uncomplicated wound dressing changes.
- Level 2 (99282, G0381): Any Level 1 services plus point-of-care testing (urine dipstick, stool occult blood, glucose); visual acuity exam; specimen collection by lab; cast removal by ED staff; repair of wound with skin adhesive; non-prescription medication administered; prep/assist with simple procedures (minor laceration repair, I&D of simple abscess).
- Level 3 (99283, G0382): Any Level 1–2 services plus receipt of EMS/ambulance patient; heparin/saline lock without parenteral meds/fluids; one nebulizer treatment; preparation for lab tests (CPT 80048–87999); preparation for plain X-rays of 1–2 body areas; prescription non-parenteral medications; Foley catheter placement; in/out catheterization; drainage of simple abscess; other items listed for Level 3.
- Level 4 (99284, G0383): Any Level 1–3 services plus preparation for one special imaging study (CT, MRI, US, V/Q); two nebulizer treatments; port-a-cath access; administration/monitoring of parenteral medications (IV/IM/IO/SC) (not local anesthesia/immunization booster); nasogastric or PEG tube placement/replacement or multiple reassessments; prep/assist with intermediate procedures (eye irrigation with Morgan lens, bladder irrigation with 3-way Foley, pelvic exam without forensic collection); sexual assault exam without specimen collection; routine psychiatric medical clearance; EKG; psychotic patient not suicidal; direct admit via ED; C-spine precautions; corneal exam with dye; epistaxis with packing; oxygen therapy; emesis/incontinence care; joint aspiration/injection; intermediate/complex laceration repair; post-mortem care.
- Level 5 (99285, G0384): Any Level 1–4 services plus more than one special imaging study combined with multiple tests or parenteral medication; blood transfusion/products; oxygen via face mask or non-rebreather; multiple nebulizer treatments (three or more or continuous periods); procedural sedation; advanced procedures (central line insertion, gastric lavage, lumbar puncture, paracentesis); temperature instability requiring intervention; use of specialized resources (social services, police, crisis management); sexual assault exam with forensic specimen collection by ED staff; coordination of hospital admission/transfer for higher level of care; physical/chemical restraints; need for 1:1 sitter; ICU admission not otherwise meeting critical care criteria; serial cardiac studies whether or not during observation status.
- Critical Care (99291, 99292): Critical care services (first hour and add-on 30-minute intervals) are billed only with CPT codes 99291–99292 and require documentation of critical care services such as continuous IV vasoactive medications, parenteral medications requiring continuous vital sign monitoring, major trauma care, chest tube insertion, CPR, defibrillation/cardioversion, emergent airway management, ventilator management, transfusion, pacing, pericardiocentesis, therapeutic hypothermia, delivery of baby, and other life‑saving interventions.
Claims must include the most appropriate HCPCS and/or CPT codes in addition to revenue codes (e.g., 0450, 0451, 0452, 0456, 0459) as required by the Plan and provider contract. The corresponding HCPCS/CPT should be submitted on the same line as the revenue code; if multiple HCPCS/CPT codes are needed for a revenue code, include the revenue code on separate lines. Claims may be denied if required codes are not submitted.
The Plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Coding and Reimbursement

ED facility E/M and corresponding HCPCSCPT | HCPCS | mixedCovered

99281	Emergency department visit, Minor or self-limiting complaint (Level 1)
99282	Emergency department visit (Level 2)
99283	Emergency department visit (Level 3)
99284	Emergency department visit (Level 4)
99285	Emergency department visit (Level 5)
G0380	Level 1 hospital ED visit (type B ED)
G0381	Level 2 hospital ED visit (type B ED)
G0382	Level 3 hospital ED visit (type B ED)
G0383	Level 4 hospital ED visit (type B ED)
G0384	Level 5 hospital ED visit (type B ED)

1–10 of 12

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Required revenue codes for electronic outpatient facility claimsRevenueCovered

0450	Outpatient claim revenue code example
0451	Outpatient claim revenue code example
0452	Outpatient claim revenue code example
0456	Outpatient claim revenue code example
0459	Outpatient claim revenue code example

Documentation threshold for billing an ED facility level

RequirementAt least one documented service from the Possible Services Rendered list must be present in the member's medical record to support reimbursement for the billed ED facility level (99281-99285 / G0380-G0384).

ScopeApplies to facility ED level determination for claims billed on CMS 1500 and/or UB04 for Place of Service 23 (in‑network and out‑of‑network facilities).

ApplicationA facility level may encompass multiple possible services and is not limited to a single listed service; documentation of any one qualifying service is sufficient to satisfy the threshold.

Exclusion noteServices provided while a member is in observation status generally do not count toward a higher ED facility level unless explicitly noted or governed by provider contract.

Provider Actions and Documentation

Documentation Required

Documentation and supporting codes required

The Plan reserves the right to request supporting documentation. Failure to adhere to coding and billing policies may impact claims processing and reimbursement. The member's medical record documentation for the diagnosis and treatment of services rendered in the ED must indicate the presenting symptoms, diagnoses, treatment plan and a written order by the provider. All contents of medical records should be clearly documented. Medical records and itemized bills may be requested from the facility/provider for review to validate the site of service, level of care, and that the services billed were accurately reported. Services provided while a member is in observation status do not apply to the determination of the E/M facility code, except as noted below or per provider contract.

The Plan may request supporting documentation to validate billed services and site of service.
Providers must submit revenue codes with corresponding HCPCS/CPT codes for electronic outpatient facility claims, including but not limited to: 0450, 0451, 0452, 0456, and 0459.
Claims may be denied if a corresponding HCPCS or CPT code is not submitted with the appropriate revenue code.
HCPCS/CPT codes should be submitted on the same line as the revenue code. If more than one HCPCS or CPT code is needed for a revenue code, the revenue code should appear on a separate line for each additional code.

Key Definitions

Emergency Department facility setting (Place of Service)

DefinitionPlace of Service 23 — Emergency Department facility setting for outpatient services.

ClaimsPolicy applies to ED services billed on CMS 1500 and/or UB04 when Place of Service is 23.

Coding requirementClaim submissions must contain revenue codes that reflect the services rendered and compatible HCPCS/CPT codes.

Critical care services (ED)

DefinitionCritical care services — services for the critically ill or injured that include life‑saving interventions (e.g., parenteral vasoactive infusions, major trauma care, chest tube insertion, CPR, intubation, ventilator management).

BillingCritical care must be billed using CPT codes 99291 (first 30–74 minutes) and 99292 (each additional 30 minutes).

Relationship to ED levelsCritical care may include items from Levels 1–5 plus critical interventions; ICU admission that does not meet critical care criteria is listed under Level 5.

DocumentationDocumentation must support the presence of critical interventions and continuous monitoring to justify billing 99291/99292.

OpenPayer

Emergency Department Services Evaluation and Management - E/M Coding - Facility Services

Coverage Criteria

Coding and Reimbursement

Provider Actions and Documentation

Key Definitions