Currentblue cross blue shield - tennesseePolicy N/A

Code Editing for Facility High Level Emergency Room Services

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This policy governs BlueCross BlueShield of Tennessee's pre-payment code editing and evaluation of high-level emergency room (ER) facility service codes using ACEP-guided, resource-utilization-based criteria; it affects facility claims submitted to BCBS TN beginning July 1, 2024.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyCode Editing for Facility High Level Emergency Room Services

Policy CodePolicy N/A

Change TypeAdded pre-payment code editing program

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionIf you disagree with a determination, file a corrected claim or an appeal with supporting documentation; BCBS TN will review the submitted medical record.

SourceLink

POLICY UPDATE CHANGES

Beginning July 1, 2024, BlueCross BlueShield of Tennessee will evaluate and pre-pay code edit facility claims for the appropriateness of high-level ER services using ACEP guidelines.

July 1, 2024policy effective date

ACEPprimary evaluation method

pre-paymentediting timing

Evaluation and Coverage Criteria

Evaluation and appeal process

Pre-payment code editing evaluation for facility high-level ER services will incorporate ACEP facility guidelines and CMS/AMA guidance on facility-level assignment.

Evaluate submitted facility ER high-level service codes using ACEP facility-level criteria and resource utilization evidence (nursing and ancillary staff, interventions).

Based on the outcome of the pre-payment evaluation, the submitted facility ER code may be downcoded to the appropriate level and reimbursement adjusted accordingly.

Facility-level ER assignment is based solely on resource utilization (nursing and ancillary staff and interventions) rather than the physician's medical decision-making; ACEP criteria and CMS/AMA guidance will guide the assessment.

If the provider disagrees with a determination, the provider may submit a corrected claim or file an appeal with supporting medical record documentation; BCBS TN will review the submitted medical record to assess intensity of service and complexity of medical decision-making.

Facility ER Codes and Assessment Basis

Facility ER level codes (high-level)mixed

No codes listed

inv-03: Assessment basis

Assessment basisFacility-level ER assignment is determined based on resource utilization (nursing and ancillary staff) and interventions rather than the physician's medical decision-making.

Primary evaluation timingPre-payment code editing evaluation of facility high-level ER service claims begins July 1, 2024.

Possible actionSubmitted facility ER codes may be downcoded and reimbursement adjusted if documentation does not support billed level.

Documentation reviewBCBS TN will review the submitted medical record to assess intensity of service and complexity if appealed.

Appeals, Corrected Claims, and Provider Responsibilities

Prior Authorization

File corrected claims or appeals with supporting documentation

If you disagree with a determination, you may file a corrected claim or an appeal with the appropriate documentation to support the level of the services billed. BCBS TN will review the submitted medical record to assess the intensity of service and complexity of medical decision‑making. For additional details on appeals, refer to the Commercial Provider Administration Manual or contact customer service.

Submit a corrected claim or formal appeal with the medical record and supporting documentation that justify the billed facility ER level.
BCBS TN will review the submitted medical record to assess intensity of service and complexity of medical decision‑making when evaluating the appeal.
See the Commercial Provider Administration Manual or contact customer service for procedural details and timelines.

Key Definitions

inv-05: Definition of facility-level ER assignment

DefinitionFacility-level ER assignment is the determination of emergency department service level based on resource utilization (nursing and ancillary staff) and interventions, not on the physician's medical decision-making.

Distinction from physician E&MCMS and AMA guidance address physician E&M elements, but CMS advises facility assignment should be based solely on resource utilization.

Supporting methodologyACEP has published facility-level criteria and tools that consider possible interventions and potential symptoms to support assignment.

inv-06: ACEP guidelines

SourceAmerican College of Emergency Physicians (ACEP) facility-level ER criteria and tools (ED Facility Level Coding Guidelines; ACEP Facility Guidelines).

What it coversCriteria and tools consider possible interventions and potential symptoms with examples to support facility-level ER assignments.

Integration into BCBS TN policyACEP guidelines will be incorporated into BCBS TN's pre-payment code editing evaluation for facility high-level ER services starting July 1, 2024.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyCode Editing for Facility High Level Emergency Room Services

Policy CodePolicy N/A

Change TypeAdded pre-payment code editing program

Effective DateJul 1, 2024

Next Review DateN/A

Key ActionIf you disagree with a determination, file a corrected claim or an appeal with supporting documentation; BCBS TN will review the submitted medical record.

SourceLink

On This Page

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Code Editing for Facility High Level Emergency Room Services

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Evaluation and Coverage Criteria

Evaluation and appeal process

Pre-payment code editing evaluation for facility high-level ER services will incorporate ACEP facility guidelines and CMS/AMA guidance on facility-level assignment.

Evaluate submitted facility ER high-level service codes using ACEP facility-level criteria and resource utilization evidence (nursing and ancillary staff, interventions).

Based on the outcome of the pre-payment evaluation, the submitted facility ER code may be downcoded to the appropriate level and reimbursement adjusted accordingly.

Facility ER Codes and Assessment Basis

Facility ER level codes (high-level)mixed

No codes listed

inv-03: Assessment basis

Assessment basisFacility-level ER assignment is determined based on resource utilization (nursing and ancillary staff) and interventions rather than the physician's medical decision-making.

Primary evaluation timingPre-payment code editing evaluation of facility high-level ER service claims begins July 1, 2024.

Possible actionSubmitted facility ER codes may be downcoded and reimbursement adjusted if documentation does not support billed level.

Documentation reviewBCBS TN will review the submitted medical record to assess intensity of service and complexity if appealed.

Appeals, Corrected Claims, and Provider Responsibilities

Prior Authorization

File corrected claims or appeals with supporting documentation

Submit a corrected claim or formal appeal with the medical record and supporting documentation that justify the billed facility ER level.
BCBS TN will review the submitted medical record to assess intensity of service and complexity of medical decision‑making when evaluating the appeal.
See the Commercial Provider Administration Manual or contact customer service for procedural details and timelines.

Key Definitions

inv-05: Definition of facility-level ER assignment

Distinction from physician E&MCMS and AMA guidance address physician E&M elements, but CMS advises facility assignment should be based solely on resource utilization.

Supporting methodologyACEP has published facility-level criteria and tools that consider possible interventions and potential symptoms to support assignment.

inv-06: ACEP guidelines

SourceAmerican College of Emergency Physicians (ACEP) facility-level ER criteria and tools (ED Facility Level Coding Guidelines; ACEP Facility Guidelines).

What it coversCriteria and tools consider possible interventions and potential symptoms with examples to support facility-level ER assignments.

Integration into BCBS TN policyACEP guidelines will be incorporated into BCBS TN's pre-payment code editing evaluation for facility high-level ER services starting July 1, 2024.