CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP042

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

Defines coding, documentation, and reimbursement expectations for professional providers billing Emergency Department E/M services to Blue Cross and Blue Shield of Oklahoma; applies to physicians and other qualified health care professionals submitting CMS 1500 professional claims.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

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

Policy CodePolicy CPCP042

Change TypeAnnual Review

Effective DateOct 3, 2024

Next Review Date

Key ActionSubmit complete medical records and itemized bills upon request to validate services and the billed level of care.

SourceLink

POLICY UPDATE CHANGES

Annual Review recorded on 09/24/2024.

5ED E/M CPT codes listed (99281-99285)

4Levels of Medical Decision Making

2Policy update entries

Coverage and Reimbursement Criteria

Coverage criteria for ED E/M services

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ALL of the following

ALL of the following
- Provider must document chief complaint, diagnoses, treatment plan, all tests and imaging, and all written orders in the medical record to support services billed.
- All medical record contents (clinical notes, consultation notes, lab/pathology/radiology testing) should be clearly documented and signed.
- Medical records and itemized bills may be submitted to validate site of service, level of care rendered, and services billed.
ALL of the following
- Claims must use the applicable ED E/M CPT code that corresponds to the level of MDM (99281-99285). Inclusion of a code does not guarantee reimbursement; codes may be subject to review prior to payment.
- The E/M ED CPT codes are inclusive of medically appropriate history and/or physical examination when performed; extent of history/exam documentation is not required by this policy for reimbursement.
ALL of the following
- The Emergency Department E/M level is determined by Medical Decision Making (MDM); time is not a descriptive component for ED E/M levels.
- MDM is measured by three elements: (1) number and complexity of problems addressed, (2) amount and complexity of data to be reviewed and analyzed, and (3) risk of complications and/or morbidity or mortality of patient management.
- To qualify for a specific MDM level (straightforward, low, moderate, high), at least 2 of the 3 MDM elements must be met or exceeded. (Exception: MDM requirement does not apply to CPT code 99281.)
ALL of the following
- Claim submissions may be reviewed to determine the level of MDM and services rendered; submitted documentation will be evaluated to determine if the billed level of service is supported.
- If documentation does not support the billed level, payment may be adjusted and providers may be asked to submit additional records or itemized bills to validate services.

ED Evaluation & Management Codes and MDM Rules

Emergency Department 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 determination requirement

MDM elements requirementTo qualify for a specific MDM level (except CPT 99281), at least 2 of the 3 MDM elements (number/complexity of problems, amount/complexity of data, and risk of significant complications/morbidity/mortality) must be met or exceeded.

Applicable exceptionLevel of MDM does not apply to CPT code 99281.

MDM levelsFour MDM levels defined: straightforward, low, moderate, and high.

Elements definedThe three MDM elements are: (1) Number and complexity of problems addressed; (2) Amount and/or complexity of data to be reviewed/obtained; (3) Risk of significant complications, morbidity, and/or mortality.

Documentation implicationED E/M level is determined by MDM; time is not a descriptive component for ED E/M services.

Definitions

Medical Decision Making (MDM) definitions

Definition - MDMMedical Decision Making (MDM) is the process used to determine the Emergency Department E/M service level based on problems addressed, data complexity, and risk.

Problem elementNumber and complexity of problems addressed: ranges from 1 (self-limited/minor) to 4 (one or more illnesses posing threat to life or bodily function).

Data elementAmount and/or complexity of data to be obtained, reviewed, or analyzed: classified as minimal/none, limited, moderate, or extensive.

Risk elementRisk of significant complications, morbidity, and/or mortality from diagnostic testing or treatment: minimal, low, moderate, or high.

Use in ED codingED E/M CPT codes are inclusive of medically appropriate history and/or physical exam when performed; MDM — not time — determines ED E/M level.

Claims Review and Documentation Requests

Documentation Required

Claims may be reviewed and documentation may be requested

Claims may be subject to review prior to payment; upon request providers must submit additional documentation such as medical records and itemized bills to validate site of service, level of care, and services billed.

Providers are urged to submit any additional documentation upon request (e.g., medical records, itemized bills).
Documentation must include chief complaint, diagnoses, treatment plan, tests/imaging, written orders, and signed clinical notes to support billed services.