Coming later in 2022: Coding update for Medicare Plus Blue outpatient emergency department claims

Blue Cross Blue Shield of Michigan will enhance its claim editing process later this year for evaluation and management services on outpatient facility emergency department claims for Medicare Plus Blue℠ members. We’re making this update to promote correct coding and assist with payment accuracy.

This coding update focuses on outpatient facility emergency department claims that are submitted with Level 4 (*99284, G0383) or Level 5 (*99285, G0384) E/M codes. The process was developed to address inconsistencies in coding accuracy nationwide.

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 follow the intent of Current Procedural Terminology, or CPT^®, code descriptions and relate to hospital resource use. 

CPT code levels:

• *99281 — ER visit for the evaluation and management of a patient (Level 1)
• *99282 — ER visit for the evaluation and management of a patient (Level 2)
• *99283 — ER visit for the evaluation and management of a patient (Level 3)
• *99284 — ER visit for the evaluation and management of a patient (Level 4)
• *99285 — ER visit for the evaluation and management of a patient (Level 5)

This coding update will apply to all facilities, including freestanding facilities, that submit outpatient emergency department claims with Level 4 or Level 5 E/M codes. The facilities may experience adjustments to the submitted code to reflect an appropriate-level E/M code.

Optum EDC Analyzer™ tool

As part of the implementation of this process, we’ll begin using the Optum EDC Analyzer tool. The 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 even try running a claim through the tool — visit EDCAnalyzer.com.**

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 (for example: 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 years old
• Claims with certain diagnosis codes that when treated in the emergency department most often necessitate greater-than-average resource usage, 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.

Note: The appeal process won’t change. Submitters who believe a higher-level E/M code is justified for the 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.

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