CurrentBlue Cross Blue Shield - WisconsinPolicy C-20006

Emergency Room Transfers - Facility reimbursement

Governs reimbursement for emergency room visits when a patient is transferred between outpatient facilities under the same agreement, TIN, or common ownership; applies to facility claims for Anthem/Blue Cross Blue Shield members except where state or federal mandates or specific market exemptions apply.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyEmergency Room Transfers - Facility reimbursement

Policy CodePolicy C-20006

Change TypeRevised (operational)

Effective DateJul 17, 2024

Next Review DateN/A

Key ActionFollow authorization and medical necessity guidelines; bill services with appropriate CPT/HCPCS/revenue codes and support with medical record documentation.

SourceLink

POLICY UPDATE CHANGES

Updated code list descriptions and removed 'episodes of care' from the Definition section.

oneER visit reimbursed when transfer occurs between facilities under same agreement/TIN/common ownership

99281-99285Related ED evaluation and management CPT codes listed

Maine, NHMarkets exempt from this policy

07/17/2024Last approval/effective date

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Emergency Room Transfer reimbursement criteria

Reimbursement conditions for emergency room transfers:

ALL of the following

Transfer between outpatient facilities that operate under the same agreement, the same tax identification number (TIN), or are under common ownership.
The Health Plan considers the transfer a single episode of care and will allow reimbursement for one emergency room visit only.
The transferring facility is not eligible for separate reimbursement when the transfer is between facilities described above.
Claims must follow authorization, medical necessity, and proper billing guidelines and be supported by the medical record; services should be billed using appropriate CPT/HCPCS/revenue codes (see ED E/M codes 99281-99285).

Exceptions

Maine is not subject to this policy.
New Hampshire is not subject to this policy.

Compliance note: Federal, state, provider contract, and mandate requirements may supersede this policy; follow applicable laws and member benefit terms.

Emergency Department Evaluation & Management Codes

ED E/M codesCPT

99281	Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.
99282	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
99283	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
99284	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
99285	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

Billing, Authorization, and Documentation Requirements

Billing Rule

Billing, authorization, and documentation requirements for ER transfers

Follow authorization and medical necessity guidelines and bill services with industry-standard CPT/HCPCS/revenue codes supported by the medical record. Transfers between outpatient facilities under the same agreement, same TIN, or common ownership are considered a single episode of care; only one ER visit is reimbursable and the transferring facility is not eligible for separate reimbursement.

Use Current Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes on all claim submissions.
Ensure billed services are fully supported in the medical record and/or office notes.
Be aware that failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and recovery/recoupment of payment.

Key Definitions

Emergency Services — definition of emergency services/medical condition

DefinitionA medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson with average health/medical knowledge could reasonably expect lack of immediate medical care to result in serious jeopardy, serious impairment/dysfunction of a bodily organ or part, serious disfigurement, or (for a pregnant woman) serious jeopardy to her or her unborn child.

ScopeThis definition applies to Emergency Services as used in the Health Plan's reimbursement and coverage policies.

Layperson standardEvaluation is based on what a prudent layperson could reasonably expect, not on retrospective clinical determination.

Emergency Room Transfer (facility reimbursement stance)

Primary ruleWhen a patient is transferred between outpatient facilities operating under the same agreement, the same TIN, or under common ownership, the Health Plan allows reimbursement for one emergency room visit and considers the transfer a single episode of care.

Transferring facility reimbursementThe transferring facility will not be eligible for separate reimbursement when the transfer is between facilities described above.

ExceptionsProvider contracts, state or federal mandates, or other regulatory requirements may supersede this policy.