Updates to Emergency Department Facility Evaluation and Management Coding Policy
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Governance of outpatient facility Emergency Department evaluation and management (E/M) coding reimbursement for Level 4 and Level 5 ED claims submitted to McLaren Health Plan lines of business listed, affecting all outpatient facilities including freestanding sites.
McLaren will begin using the Optum Emergency Department Claim (EDC) Analyzer tool to determine appropriate E/M coding levels.
Policy explicitly applies to all outpatient facilities (including freestanding) submitting ED level 4 or 5 E/M codes regardless of network participation.
Lists exclusions where the ED E/M policy will not apply (e.g., admissions from ED, transfers, critical care, patients under two years old, certain diagnoses, deaths in ED).
Specifies the impacted E/M codes: 99284/G0383 (Level 4) and 99285/G0384 (Level 5).
Coverage criteria and exclusions
Coverage criteria and exclusions for ED facility E/M coding
Covered when ALL of the following apply, except where listed exclusions remove a claim from policy application or automated review:
EXCLUSIONS — policy and EDC Analyzer do NOT apply if ANY of the following are present:
- Member was admitted from the ED or transferred to another health care setting (e.g., Skilled Nursing Facility, Long Term Acute Care Hospital).
- Member is under two years of age.
- Claim contains certain diagnosis codes that typically require greater-than-average resources when treated in the ED (for example, conditions necessitating significant nursing time).
- Member expired in the ED.
Targeted and excluded codes; age-based exclusion
EDC Analyzer review and provider support
EDC Analyzer review may trigger denials if E/M level not supported
McLaren will review outpatient facility ED claims with Level 4 or Level 5 E/M codes using the Optum Emergency Department Claim (EDC) Analyzer. Claims that do not reflect an appropriate E/M level based on the EDC Analyzer review may receive a denial per the reimbursement structure and contract terms; providers are therefore exposed to potential claim denials if submitted E/M levels are not supported by claim data (presenting problem, diagnostics, complicating conditions).
- EDC Analyzer determines appropriate E/M level using claim data: member presenting problem, diagnostic services, and patient complicating conditions.
- Claims that do not reflect an appropriate level may receive a denial, in accordance with reimbursement structure and contract terms.
Contact Provider Relations / McLaren CONNECT for training
For questions, concerns, or training on using the McLaren CONNECT provider portal, contact your Provider Relations Representative at 888-327-0761 (TTY: 711) or visit mclarenhealthplan.org for assistance and resources.
- Contact Provider Relations for assistance or training on the McLaren CONNECT portal: 888-327-0761 (TTY: 711).
- Visit mclarenhealthplan.org for more information.
Key definitions
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