Update: Emergency Department Claims Analyzer implementation

In a February Record article, we wrote about the proposed expansion of Blue Cross Blue Shield of Michigan’s claim editing process, aimed at promoting correct coding through the Optum Emergency Department Claim Analyzer tool, and asked for input from our facilities. Based on that input, we’re providing some additional information below:

• Currently, the EDC Analyzer only recodes from a higher-level Evaluation and Management, or E/M code, to a lower-level code.
• To appeal an EDC Analyzer claim, follow the current clinical editing appeals process.
• EDC Analyzer is now the Blue Cross payment policy, and claims can be modeled at EDSAnalyzer.com.**
• Blue Cross recognizes that there are different methodologies that can be used to arrive at the appropriate CPT code. However, we’ll adhere to the EDC Analyzer tool, which uses ICD-10 and CPT codes as the basis for E/M selection.   
• This is how EDC Analyzer claims will be processed:
• Hospitals that are reimbursed through a fee schedule for outpatient services won’t have their claims denied, but instead will be reimbursed using the EDC Analyzer recommended code.
• Hospitals that are reimbursed a percentage of the charge for outpatient services will have their claims denied if submitted with an incorrect code and the recommended E/M code will be reflected on the voucher. Hospitals should rebill with the EDC Analyzer recommended code.

Following Blue Cross Blue Shield of Michigan’s review of facility input, we’ll be moving forward with this program, effective early October 2022. Details about the EDC Analyzer were also presented at the May 16 Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and the PHA Advisory Committee, which was held on June 21.

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