CurrentHumanaPolicy CP2017009

Emergency Department E/M Reimbursement

Defines Humana's criteria and reimbursement approach for facility emergency department evaluation and management (E/M) services (CPT 99281-99285; HCPCS G0380-G0384) for Medicare Advantage, Kentucky Medicaid and Oklahoma Medicaid products.

Policy Summary

PayerHumana

PolicyEmergency Department E/M Reimbursement

Policy CodePolicy CP2017009

Change TypeNo material change

Effective DatePublished 04/2018

Next Review Date

Key ActionCompare billed facility ED E/M service codes to the policy criteria and reimburse at the supported level when documentation does not support the billed higher level.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 99281-99285Listed facility ED E/M CPT codes

G0380-G0384Listed facility ED E/M HCPCS codes

3Applies to products

04/2018, 03/2025Document dates

Emergency Department E/M Reimbursement Criteria

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Level 1 (99281, G0380)

One or more of the following: initial assessment; no medication or treatments; prescription refill only; note for work or school; wound recheck; booster or follow-up immunization without injury or with minor acute injury; dressing changes; suture removal.

Level 2 (99282, G0381)

One or more of the following: simple tests and cultures performed by ED staff (clean catch urine, accucheck(s), stool smear, throat/skin/urine/wound cultures); visual acuity exam; ace wrap or sling application; preparation/assistance with minor laceration repair or incision and drainage of simple abscess; cast removal; foreign body removal without incision or anesthetic; first or second degree burn treatment with discharge; venipuncture for lab test; suture removal.

Level 3 (99283, G0382)

One or more of the following: heparin or saline lock placement; one nebulizer treatment; X-ray of one or more body areas; prescription medication administration by mouth (PO); insertion or removal of Foley catheter or catheter to obtain sterile urine specimen; cervical spine precautions; fluorescein stain eye test; emesis or incontinence care; joint aspiration or joint injection; simple fracture care; simple mental health treatment or routine psychiatric medical clearance; limited social worker intervention (case management); postmortem care; direct admission via ED; epistaxis treatment with packing; routine tracheotomy care; simple eye or ear irrigation; simple treatment of dislocation without fracture; assault treatment without radiological testing; port-a-cath venous access; pelvic, genitourinary or rectal examination; IV push medication; IV fluid without medication; IM or Sub-Q medication administration.

Level 4 (99284, G0383)

One or more of the following: special imaging study (CT, ECHO, MRI, ultrasound, VQ); two non-continuous nebulizer treatments or ≥1 hour continuous nebulizer treatment; administration and monitoring of infusions or parenteral medication (IV, IM, intraosseous or vascular catheterization); nasogastric (NG) or PEG tube placement or replacement; preparation/assistance with procedures (Morgan Lens, bladder irrigation with three-way Foley); sexual assault exam without specimen collection; treatment of nonsuicidal psychotic patient; insertion of nasal or oral airway; PICC or central line insertion; tracheal tube replacement; complete series of rabies vaccines; four or more different types of diagnostic tests (multiple tests of same type count as one type; exception: each X-ray counts separately); blood transfusion administration (see Level 5 for more intensive transfusion criteria); moderate sedation; preparation/assistance with procedures such as lumbar puncture, paracentesis or thoracentesis (Level 5 includes highest severity items).

Level 5 (99285, G0384)

One or more of the following: blood transfusion administration; three or more non-continuous nebulizer treatments or ≥2 hours continuous nebulizer treatment; critical care for <30 minutes; moderate sedation; complex procedures (lumbar puncture, paracentesis, thoracentesis); treatment for severe burns; general anesthesia; preparation/assistance with complex or prolonged resuscitative or procedural interventions; extended social worker intervention; coordinating transfer for hospital admission or change in living situation; administration of physical or chemical restraints; suicide watch; fracture reduction or relocation; decontamination or isolation for hazardous material; precipitous delivery in ED.

Facility ED E/M Codes and Level-specific Minimums

Facility ED E/M codesmixed

99281	Level 1 facility ED E/M (Type A)
99282	Level 2 facility ED E/M (Type A)
99283	Level 3 facility ED E/M (Type A)
99284	Level 4 facility ED E/M (Type A)
99285	Level 5 facility ED E/M (Type A)
G0380	Level 1 hospital ED visit (Type B)
G0381	Level 2 hospital ED visit (Type B)
G0382	Level 3 hospital ED visit (Type B)
G0383	Level 4 hospital ED visit (Type B)
G0384	Level 5 hospital ED visit (Type B)

Facility ED E/M 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 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.

Facility ED E/M HCPCS codesHCPCS

G0380	Level 1 hospital emergency department visit provided in a type B emergency department.
G0381	Level 2 hospital emergency department visit provided in a type B emergency department.
G0382	Level 3 hospital emergency department visit provided in a type B emergency department.
G0383	Level 4 hospital emergency department visit provided in a type B emergency department.
G0384	Level 5 hospital emergency department visit provided in a type B emergency department.

Minimum criteria by ED E/M level

Level 1 (99281, G0380)One or more: initial assessment; no medication/treatments; prescription refill only; note for work/school; wound recheck; booster/follow-up immunization without injury or with minor acute injury; dressing changes; suture removal.

Level 2 (99282, G0381)One or more: simple tests/cultures (clean catch urine, accucheck, stool smear, throat/skin/urine/wound cultures); visual acuity; ace wrap/sling; minor laceration repair; incision and drainage of simple abscess; cast removal; foreign body removal without incision/anesthetic; first/second degree burn treatment with discharge; venipuncture for lab test.

Level 3 (99283, G0382)One or more: heparin/saline lock placement; one nebulizer treatment; X-ray of one or more body areas; PO medication administration; Foley catheter insertion/removal; cervical spine precautions; fluorescein stain eye test; emesis/incontinence care; joint aspiration/injection; simple fracture care; simple mental health treatment; IV push or IV fluids; IM/Sub-Q medication administration; limited social worker intervention; pelvic/genitourinary/rectal examinations.

Level 4 (99284, G0383)One or more: special imaging (CT, ECHO, MRI, ultrasound, VQ); two non-continuous nebulizers or ≥1 hour continuous; administration/monitoring of infusions or parenteral meds (IV/IM/IO/VC); NG/PEG tube placement/replacement; PICC/central line insertion; tracheal tube replacement; bladder irrigation with three-way Foley; Morgan Lens; insertion of nasal/oral airway; complete series of rabies vaccines; four or more different diagnostic test types.

Level 5 (99285, G0384)One or more: blood transfusion administration; three or more non-continuous nebulizer treatments or ≥2 hours continuous nebulizer treatment; critical care <30 minutes criteria (highest severity items); moderate sedation; complex procedures (lumbar puncture, paracentesis, thoracentesis); treatment for severe burns; general anesthesia; prolonged/complex resuscitative or procedural interventions.

OpenPayer

Emergency Department E/M Reimbursement

Emergency Department E/M Reimbursement Criteria

Facility ED E/M Codes and Level-specific Minimums

Authorization, Payment Conditions, and Provider Requirements

ED E/M Level Definitions