Here’s what you need to know about the Emergency Department Claim Analyzer tool and how to provide input

Blue Cross Blue Shield of Michigan is proposing an expansion of its claim editing process aimed at promoting correct coding through the Optum Emergency Department Claim Analyzer™ tool. This initiative will target evaluation and management codes, also called E/M codes, on emergency department claims for Blue Cross commercial members. Blue Cross will deploy the EDC analyzer tool in the fourth quarter of 2022.

The EDC analyzer is an automated tool that accurately calculates the appropriate claim visit level for an emergency department visit. It’s based on the E/M coding principles developed by the Centers for Medicare & Medicaid Services. These principles help ensure that hospital emergency department E/M coding guidelines align with the intent of CPT code descriptions and related hospital resource use. 

This proposed coding update will apply to all facilities, including freestanding facilities. The EDC Analyzer is expected to improve emergency department coding inconsistencies by applying all 11 CMS guidelines for coding outpatient facility visit levels. Facilities may experience adjustments to the submitted code to reflect an appropriate E/M code.

Blue Cross provided notification of this program for Medicare Plus Blue℠ in an article in the January edition of The Record.

What this means to hospitals

The Optum EDC Analyzer tool determines appropriate E/M coding levels based on data from a patient’s claim, and includes the following: 

• Patient’s presenting problem
• Diagnostic services performed during the visit
• Any of the patient’s complicating conditions

To learn more about the EDC Analyzer tool and to try running a claim through the tool, visit EDCAnalyzer.com.**

The proposed EDC Analyzer will:

• Review ICD-10 and CPT codes on submitted facility claims.
• Assign weights to each code; the weights are then totaled, recommending the appropriate visit level.
• Not deny facility claims; claims are paid at the newly determined E/M level.
• If the EDC Analyzer finds that a lower-level emergency department code is warranted instead of the code billed, the billed emergency department  code will be denied and a new claim line will be added to the voucher with the payable emergency department code.
• Represent an administrative review, not a medical necessity review.
• Up to 24 diagnosis codes can be submitted on a claim and all will be considered by the EDC Analyzer.

Exclusions

Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

• Claims for patients who were admitted from the emergency department or transferred to another health care setting (such as a skilled nursing facility or long-term care hospital)
• Claims for patients who received critical care services (*99291,*99292)
• Claims for patients who are younger than 2
• Claims with certain diagnosis codes that, when treated in the emergency department, most often necessitate greater-than-average resource use, such as significant nursing time
• Claims for patients who died in the emergency department

Ultimately, the goal of facility coding is to accurately capture emergency department resource utilization and align that with the E/M CPT code description for a patient visit per CMS guidance.

What this means to hospitals

There will be consistent reimbursement methodology across all facilities, with the ultimate goal of:

• Accurately capturing emergency department resource utilization
• Aligning with the E/M CPT code descriptions and CMS compliance
• Not denying claims

If there’s a claim dispute, the provider can submit an appeal through the Clinical Editing Appeal Process. Educational seminars will be available for providers to learn more about this process and ask questions.

Note: The appeal process won’t change. Submitters who believe a higher-level E/M code is justified for an outpatient emergency department visit should send an appeal on the Clinical Editing Appeal Form with the necessary documentation. Remember to continue to fax one appeal at a time to avoid processing delays.
 
EDC Analyzer example

An 80-year-old male comes to the emergency department with a diagnosis of visual disturbance and nicotine dependence. Using this process, this claim is billed as a *99285 and would be adjusted to *99284.

Testing/diagnostics

• *85025 BLOOD COUNT COMPLETE AUTO & AUTO DIFRNTL WBC
• *81003 URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY
• *80053 COMPREHENSIVE METABOLIC PANEL
• *74170 CT HEAD/ BRAIN WITH CONTRAST

Final diagnoses

• H539 Unspecified visual disturbance
• Z87891 Personal history of nicotine dependence

Overview

• Workup consisted of labs and a CT of the brain. The resource utilization was moderate and the final diagnosis, while requiring immediate care and could be considered high severity, didn’t appear to be a presentation of an immediate significant threat to life or physiologic function. Therefore, *99284 is appropriate.

Input requested

Through the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — Blue Cross is asking facilities to provide nonbinding input on this initiative.

All nonbinding facility input is due by Feb. 28, 2022, to Liz Bowman at ebowman@bcbsm.com. Once all the facility input is received, Blue Cross has 30 calendar days to give an industry-wide response.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.