CurrentBlue Cross Blue Shield - TexasPolicy CPCP003

Emergency Department Services E/M Coding - Facility Services

Defines facility-level Emergency Department (ED) evaluation and management (E/M) coding and billing guidance for in-network and out-of-network hospital ED claims (Place of Service 23), including required revenue/HCPCS/CPT code pairings and documentation expectations.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyEmergency Department Services E/M Coding - Facility Services

Policy CodePolicy CPCP003

Change TypeClarified/administrative

Effective DateOct. 6, 2025

Next Review Date

Key ActionProviders must submit supporting documentation upon request and include appropriate HCPCS/CPT codes paired with revenue codes on claims to avoid denials.

SourceLink

POLICY UPDATE CHANGES

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

6ED facility level CPT/HCPCS code groupings described (levels 1-5, critical care)

Required revenue codes listedRevenue codes required to pair with CPT/HCPCS (examples listed)

Policy history entriesPolicy Update History entries shown

Emergency Department Facility Level Coverage Criteria

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ED facility level coding criteria

Facility level of care is determined by the services rendered. At least one (1) service under the Possible Services Rendered column must be documented in the member's medical record to satisfy reimbursement for the CPT or HCPCS billed for the facility level of care code.

Level 1 (99281 / G0380): Initial assessment or minimal services. Possible services include: initial assessment; no care rendered (e.g., elopes prior to evaluation); medication refill for emergency need or behavioral health; work or school excuse; simple wound recheck; booster or follow-up immunization only; uncomplicated wound dressing changes.

Level 2 (99282 / G0381): Any items or services from Level 1 plus low-complexity services. Possible services include: point-of-care testing by ED staff (urine dipstick, stool occult blood, glucose); visual acuity exam; collection of specimens by lab; cast removal by ED staff; repair of wound with skin adhesive; administration of non-prescription medication; preparation or assistance with simple/minor procedures (simple laceration repair, incision & drainage of simple abscess, etc.).

Level 3 (99283 / G0382): Any items or services from Levels 1–2 plus moderate services. Possible services include: receipt of EMS/ambulance patient; heparin/saline lock (no parenteral meds or fluids); one nebulizer treatment; preparation for lab tests (CPT 80048-87999); preparation for plain X-rays of one or two body areas (not above/below joint of same limb); prescription non-parenteral medications; Foley catheter placement; in-and-out catheterization; drainage of simple abscess.

Level 4 (99284 / G0383): Any items or services from Levels 1–3 plus advanced services. Possible services include: preparation for one special imaging study (CT, MRI, Ultrasound, V/Q); two nebulizer treatments; port-a-cath venous access; administration and monitoring of parenteral medications (IV, IM, IO, SC) (excluding local anesthesia or immunization boosters); nasogastric/PEG tube placement or replacement or multiple reassessments; preparation or assistance with procedures such as eye irrigation with Morgan lens, bladder irrigation with 3-way Foley, pelvic exam (no forensic collection); sexual assault exam without specimen collection; psychotic patient (not suicidal); EKG; C-spine precautions; corneal exam with dye; epistaxis with packing; oxygen therapy; emesis/incontinence care; joint aspiration/injection; intermediate/complex laceration repair; routine psychiatric medical clearance; post-mortem care; direct admit via ED.

Level 5 (99285 / G0384): Any items or services from Levels 1–4 plus high-complexity services. Possible services include: more than one special imaging study combined with multiple tests or parenteral medication; administration of blood transfusion/blood products; oxygen via face mask or non-rebreather; multiple nebulizer treatments (three or more, or continuous nebulizer where each 20-minute period is a treatment); procedural sedation; preparation or assistance with procedures such as 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 (EKG and/or cardiac enzymes). The continuation of ED services while in observation status is not considered a higher level of care.

Critical Care (99291, 99292): Critical care interventions and time-based billing. Possible critical care services include any items from the above levels plus: parenteral medications requiring continuous vital sign monitoring; major trauma care/multiple surgical consultants; chest tube insertion; major burn care; treatment of active chest pain in acute coronary syndrome; cardiopulmonary resuscitation; defibrillation/cardioversion; pericardiocentesis; administration of ACLS drugs in cardiac arrest; therapeutic hypothermia; non-invasive ventilation; endotracheal intubation; emergent airway intervention; ventilator management; line placement for monitoring; major hemorrhage; pacing (including external); delivery of baby. 99291 covers the first 30–74 minutes (first hour); 99292 may be reported for each additional 30-minute increment. Critical care services may only be billed with CPT codes 99291-99292.

Revenue code / CPT pairing: The Plan requires outpatient facility providers to indicate the most appropriate HCPCS and/or CPT code(s) in addition to revenue codes (examples: 0450, 0451, 0452, 0456, 0459) for electronic outpatient facility claims. These HCPCS/CPT codes should be submitted on the same line for accurate claims processing; if more than one HCPCS or CPT code is needed for a revenue code, the revenue code should also appear on a separate line. Claims may be denied if a corresponding HCPCS or CPT code is not submitted with the appropriate revenue code.

Documentation and review: A facility level of care may encompass multiple possible services rendered and is not limited to one service. The Plan reserves the right to review services in accordance with the member's benefits and may request supporting medical records to validate the site of service and level of care. Medical records must document presenting symptoms, diagnoses, treatment plan, and provider orders as applicable.

ED Facility E/M and Documentation Coding Guidance

ED facility E/M codes (CPT)CPTCovered

99281	ED visit, minor or self-limiting complaint
99282	ED visit
99283	ED visit
99284	ED visit
99285	ED visit
99291	Critical care, first hour
99292	Critical care add'l 30 min

Hospital ED visit levels (HCPCS)HCPCS

G0380	Level 1 hospital ED visit (type B ED)
G0381	Level 2 hospital ED visit
G0382	Level 3 hospital ED visit
G0383	Level 4 hospital ED visit
G0384	Level 5 hospital ED visit

inv-03: Documentation minimum

Documentation minimumAt least one (1) service listed in the Possible Services Rendered column must be documented in the member's medical record to satisfy reimbursement for the billed CPT or HCPCS facility level of care code.

Link to facility level determinationThe CPT/HCPCS code (level of care) corresponds to the Possible Services Rendered column; the appropriate facility level is determined by services rendered and may encompass multiple services.

Record contentsMedical record should document the specific service(s) performed that support the selected facility E/M level (e.g., initial assessment, point-of-care testing, nebulizer, imaging prep).

Actions, Billing Requirements and Documentation Requests

Documentation Required

Respond to documentation requests and provide complete medical records

The Plan reserves the right to request supporting documentation to validate site of service, level of care, and that billed services were accurately reported; providers should submit medical records and itemized bills when requested. Medical record documentation must indicate presenting symptoms, diagnoses, treatment plan and a written provider order. Services provided while a member is in observation status do not apply to ED facility E/M determination except as noted or per provider contract.

Submit medical records and itemized bills upon request to support the claim.
Ensure records document presenting symptoms, diagnoses, treatment plan, and a written order by the provider.

Billing Rule

Include required HCPCS/CPT with revenue codes or risk denial

Outpatient facility providers must include the appropriate HCPCS and/or CPT code(s) with revenue codes (examples: 0450, 0451, 0452, 0456, 0459) on electronic outpatient facility claims; claims may be denied if a corresponding HCPCS or CPT code is not submitted with the appropriate revenue code.

Submit the HCPCS/CPT on the same line as the revenue code for accurate claims processing.
If more than one HCPCS or CPT is needed for a revenue code, repeat the revenue code on a separate line with the additional HCPCS/CPT.

Key Definitions and Terms

inv-06: Place of Service 23

DefinitionPlace of Service 23 denotes the facility Emergency Department (ED) setting to which this policy applies.

ScopePolicy applies to in‑network and out‑of‑network facilities submitting ED claims (Place of Service - 23) using CMS 1500 and/or UB04 forms.

Claim requirementsClaims must include revenue codes compatible with corresponding HCPCS or CPT codes; incorrect combinations may delay processing.

inv-07: Possible Services Rendered

Examples (Level 1 - 99281 / G0380)Initial assessment; no care rendered (elopes prior to evaluation); medication refill for emergency need; work/school excuse; simple wound recheck; booster or follow-up immunization; uncomplicated wound dressing changes.

Examples (Level 2 - 99282 / G0381)Any Level 1 items plus point-of-care testing (urine dipstick, stool occult blood, glucose); visual acuity exam; specimen collection; cast removal by ED staff; repair with skin adhesive; non-prescription medication administration; prep/assist with simple procedures (minor laceration repair, I&D of simple abscess).

Examples (Level 3 - 99283 / G0382)Any Level 1–2 items plus receipt of ambulance patient; heparin/saline lock (no 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 or in-and-out catheterization.