CurrentFlorida BluePolicy 26-088

Emergency Department Evaluation & Management Services

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Governs reimbursement and claim adjustment rules for ED E/M CPT codes 99281-99285 for Florida Blue products (commercial and Medicare Advantage) and providers submitting CMS-1500 or equivalent claims.

Policy Summary

PayerFlorida Blue

PolicyEmergency Department Evaluation & Management Services

Policy CodePolicy 26-088

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review Date

Key ActionProviders may appeal adjusted claims by submitting supporting documentation or submit corrected claims with additional appropriate diagnosis codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99281-99285ED E/M codes addressed

5→4Automatic reassignment

Commercial & MALines of business

YesExclusions noted

Reimbursement Adjustments and Exclusions for ED E/M Services

ED E/M reimbursement criteria

Reimbursement adjustments and exclusions for ED E/M services

Claims processing uses a predefined list of low-acuity, non-emergent diagnosis codes reviewed by Florida Blue medical directors to identify claims eligible for adjustment.

ALL of the following

Claims initially coded as Level 5 (CPT 99285) will be reassigned to Level 4 (CPT 99284) when the diagnosis indicates a lower level of MDM.

The patient's primary diagnosis must be reported in the first position on the ED visit claim form; additional appropriate diagnoses should follow. If all listed codes are low-acuity, the claim remains eligible for correct coding.

Exclusions

ED services billed with other E/M services (99281-99284 and 99291-99292)
ED E/M services billed by a hospital
Patients under 2 years old
Patients with traditional Medicare as primary coverage

Providers may appeal an adjusted claim decision by submitting all documentation to support the original billed level of service; corrected claims may be submitted if additional appropriate diagnosis codes are identified.

Applicable CPT and Related Coding Rules

ED E/M and critical care CPT 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 healthcare 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.
99291	Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
99292	Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

Level 5 Diagnostic Support Threshold

ThresholdClaims initially coded as Level 5 (CPT 99285) will be reassigned to Level 4 (CPT 99284) when the submitted diagnosis codes indicate a lower level of Medical Decision Making (MDM).

ScopeApplies to emergency department (ED) professional claims reported on CMS-1500 or equivalent forms for Florida Blue products (commercial and Medicare Advantage).

RationaleAdjustment ensures ED visits are reimbursed based on the appropriate level of service when diagnosis indicates a less severe/complex condition than billed.

Claim coding requirementReport the patient’s primary diagnosis in the first position on the ED visit claim form; follow with any additional appropriate diagnosis codes.

Corrected claimsIf additional appropriate diagnosis codes are identified, a corrected claim may be submitted with the additional diagnosis codes.

Appeals, Corrected Claims, and Documentation Requirements

Denial Risk

Appeal and corrected claim process

Providers may appeal an adjusted claim decision by submitting all documentation that supports the originally billed level of service; the appeal will be reviewed and a determination made based on the additional information provided. If additional appropriate diagnosis codes are identified, submit a corrected claim with those additional diagnosis codes.

Include all clinical documentation that supports the billed ED E/M level (e.g., history, exam, MDM notes).
If new or omitted diagnosis codes are found, file a corrected claim with the additional diagnosis codes in the proper positions.
Ensure the primary diagnosis is reported in the first position on the ED visit claim form.

Key Definitions

Medical Decision Making (MDM)

DefinitionMedical Decision Making (MDM) determines the appropriate ED E/M code level (Straightforward, Low, Moderate, High) rather than patient new/established status or visit time.

Role in this policyMDM level is used to assess whether the billed ED E/M code is supported by the reported diagnosis; claims with higher billed levels may be adjusted if diagnosis indicates lower MDM.

Levels referencedStraightforward, Low, Moderate, High — with Level 5 (CPT 99285) representing high MDM subject to reassignment if not supported by diagnosis codes.

Provider actionProviders may appeal adjusted decisions by submitting documentation that supports the originally billed MDM level.

Low-acuity (Non-emergent) Diagnosis Codes

DefinitionLow-acuity, non-emergent diagnosis codes are a predefined list reviewed by Florida Blue medical directors used to identify claims eligible for adjustment.

Effect on claimsClaims with low-acuity diagnosis codes paired with a higher ED E/M level may be eligible for reimbursement adjustment or reassignment to a lower code level.

Exclusions noteIf all listed diagnosis codes on the claim are low-acuity, the claim remains eligible for correct coding review; certain claim types and demographics are excluded from review per policy.

ReferenceThe policy links to the specific list of low-acuity diagnosis codes used to determine eligibility for adjusted reimbursement; the list is reviewed by medical directors.

Policy Summary

PayerFlorida Blue

PolicyEmergency Department Evaluation & Management Services

Policy CodePolicy 26-088

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review Date

Key ActionProviders may appeal adjusted claims by submitting supporting documentation or submit corrected claims with additional appropriate diagnosis codes.

SourceLink

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Emergency Department Evaluation & Management Services

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Sign up for Florida Blue Policy 26-088 alerts

Get alerted when Policy 26-088 changes without checking for updates manually.

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

Governs reimbursement and claim adjustment rules for ED E/M CPT codes 99281-99285 for Florida Blue products (commercial and Medicare Advantage) and providers submitting CMS-1500 or equivalent claims.

Reimbursement Adjustments and Exclusions for ED E/M Services

ED E/M reimbursement criteria

Reimbursement adjustments and exclusions for ED E/M services

Claims processing uses a predefined list of low-acuity, non-emergent diagnosis codes reviewed by Florida Blue medical directors to identify claims eligible for adjustment.

ALL of the following

Claims initially coded as Level 5 (CPT 99285) will be reassigned to Level 4 (CPT 99284) when the diagnosis indicates a lower level of MDM.

Exclusions

ED services billed with other E/M services (99281-99284 and 99291-99292)
ED E/M services billed by a hospital
Patients under 2 years old
Patients with traditional Medicare as primary coverage

Applicable CPT and Related Coding Rules

ED E/M and critical care CPT 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 healthcare 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.
99291	Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
99292	Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

Level 5 Diagnostic Support Threshold

ThresholdClaims initially coded as Level 5 (CPT 99285) will be reassigned to Level 4 (CPT 99284) when the submitted diagnosis codes indicate a lower level of Medical Decision Making (MDM).

ScopeApplies to emergency department (ED) professional claims reported on CMS-1500 or equivalent forms for Florida Blue products (commercial and Medicare Advantage).

RationaleAdjustment ensures ED visits are reimbursed based on the appropriate level of service when diagnosis indicates a less severe/complex condition than billed.

Claim coding requirementReport the patient’s primary diagnosis in the first position on the ED visit claim form; follow with any additional appropriate diagnosis codes.

Corrected claimsIf additional appropriate diagnosis codes are identified, a corrected claim may be submitted with the additional diagnosis codes.

Appeals, Corrected Claims, and Documentation Requirements

Denial Risk

Appeal and corrected claim process

Include all clinical documentation that supports the billed ED E/M level (e.g., history, exam, MDM notes).
If new or omitted diagnosis codes are found, file a corrected claim with the additional diagnosis codes in the proper positions.
Ensure the primary diagnosis is reported in the first position on the ED visit claim form.

Key Definitions

Medical Decision Making (MDM)

DefinitionMedical Decision Making (MDM) determines the appropriate ED E/M code level (Straightforward, Low, Moderate, High) rather than patient new/established status or visit time.

Levels referencedStraightforward, Low, Moderate, High — with Level 5 (CPT 99285) representing high MDM subject to reassignment if not supported by diagnosis codes.

Provider actionProviders may appeal adjusted decisions by submitting documentation that supports the originally billed MDM level.

Low-acuity (Non-emergent) Diagnosis Codes

DefinitionLow-acuity, non-emergent diagnosis codes are a predefined list reviewed by Florida Blue medical directors used to identify claims eligible for adjustment.

Effect on claimsClaims with low-acuity diagnosis codes paired with a higher ED E/M level may be eligible for reimbursement adjustment or reassignment to a lower code level.

ReferenceThe policy links to the specific list of low-acuity diagnosis codes used to determine eligibility for adjusted reimbursement; the list is reviewed by medical directors.