ER Facility Level of Service
Defines WPS Health Insurance payment policy for Emergency Department (ER) facility level-of-service coding and reimbursement for commercial lines, applicable to network and non-network providers submitting UB-04 or CMS-1500 claims.
Policy revised on 03/25/2024.
Emergency Department Facility Level Coverage Criteria
ER facility level coverage criteria
Facility levels are assigned based on interventions performed by nursing and ancillary ED staff; described interventions for Levels 1–5 are used to justify facility charges. Claims may be denied if documentation does not support the assigned level.
Level 1
- Initial assessment with no medication or treatments; examples: wound recheck, booster or follow-up immunization with no acute injury, uncomplicated dressing changes, suture removal (uncomplicated), discussion of straightforward discharge instructions, prescription refill only, asymptomatic.
Level 2
- May include interventions from Level 1 plus tests by ED staff (urine dip, stool hemoccult, accucheck), visual acuity (Snellen), obtain clean catch urine, apply ace wrap or sling, prep or assist with minor procedures (minor laceration), simple discharge instructions.
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