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    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHumana ED E/M Reimbursement Policy Update | OpenPa…
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    CurrentHumanaPolicy CP2017009

    Emergency Department E/M Reimbursement

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    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
    Last ReviewMar 1, 2025
    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.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    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

    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
    99281Level 1 ED visit (Type A)
    99282Level 2 ED visit (Type A)
    99283Level 3 ED visit (Type A)
    99284Level 4 ED visit (Type A)
    99285Level 5 ED visit (Type A)
    ED facility E/M codes (HCPCS)HCPCS
    G0380Level 1 hospital ED visit (Type B)
    G0381Level 2 hospital ED visit (Type B)
    G0382Level 3 hospital ED visit (Type B)
    G0383Level 4 hospital ED visit (Type B)
    G0384Level 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.

    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 level
    Policy Summary
    PayerHumana
    PolicyEmergency Department E/M Reimbursement
    Policy CodePolicy CP2017009
    Change TypeNo material change
    Effective DatePublished 04/2018
    Last ReviewMar 1, 2025
    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
    On This Page
    Emergency Department Visit Level Coverage CriteriaED Facility E/M and Level ThresholdsProvider Requirements and Plan ConditionsCode Definitions (Levels and HCPCS)
    Foreign body removal without incision or anesthetic
  1. First or second degree burn treatment with discharge
  2. Venipuncture for a laboratory test
  3. Heparin or saline lock placement
  4. One nebulizer treatment
  5. X-ray of one or more body areas
  6. Prescription medication administration by mouth (PO)
  7. Insertion or removal of Foley catheter or catheter to obtain sterile urine specimen
  8. Cervical spine precautions
  9. Fluorescein stain eye test
  10. Emesis or incontinence care
  11. Joint aspiration or injection
  12. Simple fracture care
  13. Simple mental health treatment or routine psychiatric medical clearance
  14. Limited social worker intervention (e.g., case management)
  15. Postmortem care
  16. Direct admission via ED
  17. Epistaxis treatment with packing
    18. Cervical spine precautions
  18. Fluorescein stain eye test
  19. Emesis or incontinence care
  20. Preparation or assistance with procedures (e.g., joint aspiration/injection)
  21. Simple fracture care
  22. Simple mental health treatment or routine psychiatric medical clearance
  23. Limited social worker intervention
  24. Postmortem care
  25. Direct admission via ED
  26. Epistaxis with packing
  27. Routine tracheotomy care
  28. Simple eye or ear irrigation
  29. Simple dislocation treatment without fracture
  30. Assault treatment without radiology
  31. Port-a-cath access
  32. Pelvic, genitourinary or rectal examination
  33. IV push medication administration
  34. IV fluid administration without medication
  35. Intramuscular or subcutaneous medication administration
  36. EKG or ECG test
    37. Sexual assault examination with or without specimen collection
  37. Treatment of nonsuicidal psychotic patient
  38. Insertion of nasal or oral airway
  39. PICC or central line insertion
  40. Endotracheal or tracheal tube insertion or replacement
  41. Complete series of rabies vaccines
  42. Four or more different types of diagnostic tests (with exceptions)
    43. 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.
    Level 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