CurrentHumanaPolicy CP2017009

Emergency Department E/M Reimbursement

Defines Humana's criteria for facility-level emergency department evaluation and management (E/M) service reimbursement for Medicare Advantage, Kentucky Medicaid and Oklahoma Medicaid products, describing which CPT and HCPCS codes correspond to each ED visit level and the minimum clinical criteria used to determine appropriate payment level.

Policy Summary

PayerHumana

PolicyEmergency Department E/M Reimbursement

Policy CodePolicy CP2017009

Change TypeNo material change

Effective DatePublished 04/2018

Next Review Date

Key ActionWhen the billed ED E/M code is higher than supported by documentation, Humana reimburses at the lower E/M service code supported by the documented minimum criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99281-99285; G0380-G0384ED facility E/M codes addressed

Medicare Advantage; KY & OK MedicaidProducts governed

Level-specific listedLevels with criteria

Published 04/2018; Rev 03/2025Document dates

Emergency Department Visit Level Coverage Criteria

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ED visit level reimbursement criteria

Minimum criteria by ED service level determine acceptable reimbursement level. Each level requires one or more of the listed items to accept the billed code at that level.

ALL of the following

Codes: 99281, G0380
ANY 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

ALL of the following

Codes: 99282, 99283, G0381, G0382
ANY of the following
- Simple tests and cultures performed by ED staff (e.g., clean catch urine, accucheck, stool smear, throat/skin/urine/wound cultures)
- Visual acuity examination
- Ace wrap or sling application
- Preparation or assistance with minor procedures (e.g., minor laceration repair, incision and drainage of simple abscess)
- Cast removal

ALL of the following

Codes: 99283, 99284, 99285, G0382, G0383, G0384
ANY of the following
- Heparin or saline lock placement
- One nebulizer treatment
- X-ray of one or more body areas
- Prescription medication PO
- Insertion or removal of Foley catheter or catheter to obtain sterile urine specimen

ALL of the following

Codes: 99284, G0383
ANY 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 medications (IV, IM, IO, vascular catheterization)
- NG or PEG tube placement or replacement
- Morgan Lens or bladder irrigation with three-way Foley

ALL of the following

Codes: 99285, G0384
ANY of the following
- Blood transfusion administration
- Three or more non-continuous nebulizer treatments or at least two hours continuous nebulizer treatment

ALL of the following

When billed ED E/M code is higher than supported by documentation, Humana reimburses at the lower E/M service code supported by documentation.

ED Facility E/M and Level Thresholds

ED facility E/M codes (CPT)CPT

99281	Level 1 ED visit (Type A)
99282	Level 2 ED visit (Type A)
99283	Level 3 ED visit (Type A)
99284	Level 4 ED visit (Type A)
99285	Level 5 ED visit (Type A)

ED facility E/M codes (HCPCS)HCPCS

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)

Minimum criteria threshold by level

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

Level 2 (99282, 99283, G0381, G0382)Minimum: one or more of simple tests/cultures by ED staff (e.g., clean catch urine, accucheck, stool smear, throat/skin/urine/wound cultures); visual acuity exam; ace wrap or sling application; preparation/assistance with minor procedures (minor laceration repair, I&D of simple abscess); cast removal; foreign body removal without incision/anesthetic; first/second-degree burn treatment with discharge; venipuncture for lab test; plus other listed simple interventions.

Level 3 (99283, 99284, 99285, G0382, G0383, G0384)Minimum: one or more of heparin or saline lock placement; one nebulizer treatment; X‑ray of one or more body areas; prescription medication PO; insertion/removal of Foley or catheter for sterile urine; cervical spine precautions; fluorescein stain eye test; emesis/incontinence care; preparation/assistance with procedures; joint aspiration/injection; simple fracture care; simple mental health treatment; routine psychiatric clearance; limited social worker intervention; postmortem care; direct admission via ED; epistaxis with packing; routine tracheotomy care; simple eye/ear irrigation; simple dislocation treatment without fracture; assault treatment without radiology; port‑a‑cath access; pelvic/genitourinary/rectal exam; IV push medication; IV fluids without meds; IM or Sub‑Q medication administration.

Level 4 (99284, G0383)Minimum: one or more of special imaging study (CT, ECHO, MRI, ultrasound, VQ); two non‑continuous nebulizer treatments or ≥1 hour continuous; administration and monitoring of infusions/parenteral meds; NG or PEG tube placement/replacement; Morgan Lens or bladder irrigation with three‑way Foley; sexual assault exam without specimen collection; treatment of nonsuicidal psychotic patient; insertion of nasal/oral airway; PICC or central line insertion; tracheal tube replacement; complete rabies vaccine series; four or more different types of diagnostic tests (with exceptions).

Level 5 (99285, G0384)Minimum: one or more of blood transfusion administration; three or more non‑continuous nebulizer treatments or ≥2 hours continuous nebulizer treatment.

Payment adjustment noteWhen the billed ED E/M code is higher than supported by documentation of the above criteria, Humana may reimburse at the lower E/M service code supported by the satisfied criteria.

Provider Requirements and Plan Conditions

Prior Authorization

Prior authorization and other plan requirements may affect payment

Claims payments are subject to other plan requirements including medical necessity, reasonableness, and applicable referral or authorization requirements; Humana may reimburse at a lower E/M code when the billed code is not supported by the policy criteria.

Humana compares facility E/M charges to the policy criteria and will reimburse at the lower E/M service code supported by documentation when the billed level exceeds supported criteria.
For Kentucky Medicaid, if the criteria for the billed code are not satisfied, Humana reimburses at the ED E/M code level for which criteria are satisfied and will not reimburse at a higher code than billed.

Code Definitions (Levels and HCPCS)

CPT 99281 — Level 1 ED visit

Code99281

DefinitionEmergency 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.

Associated levelLevel 1, Type A emergency department

CPT 99282 — Level 2 ED visit

Code99282

DefinitionEmergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.

Associated levelLevel 2, Type A emergency department

CPT 99283 — Level 3 ED visit

Code99283

DefinitionEmergency 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.

Associated levelLevel 3 (listed under Type A and may map to multiple Type A codes depending on services)

CPT 99284 — Level 4 ED visit

Code99284

DefinitionEmergency 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.

Associated levelLevel 4, Type A emergency department

CPT 99285 — Level 5 ED visit

Code99285

DefinitionEmergency 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.

Associated levelLevel 5, Type A emergency department

HCPCS G0380 — Level 1 hospital ED (Type B)

CodeG0380

DefinitionLevel 1 hospital emergency department visit provided in a type B emergency department.

Associated levelLevel 1, Type B emergency department