Emergency Department Facility Evaluation and Management Coding policy implementation

In 2022, Blue Cross Blue Shield of Michigan and Blue Care Network took the Optum Emergency Department Claims Analyzer, or EDCA, through the PHA Contract Administration Process and launched the program on Jan. 4, 2023. Last fall, the program was paused to continue discussions with health care providers on coding variations and algorithms to see if there were alternative ways to reduce the trend of higher-level emergency department coding.

Based on these discussions, EDCA will be re-launched on April 1, 2024, in conjunction with a new Emergency Department Facility Evaluation and Management Coding policy for Blue Cross PPO, Medicare Plus Blue℠ PPO, BCN and BCN Advantage℠. This reimbursement policy was developed to ensure that facilities are reimbursed based on the consistent coding that correctly describes the patient’s clinical condition and the health care services provided in accordance with industry standards and guidelines.

Why implement the Emergency Department Facility Evaluation and Management Coding policy?

Currently, there is no national standard for facility assignment of evaluation and management, or E/M, code levels for outpatient services in the emergency department. This policy will provide guidance for how Blue Cross will reimburse UB claims billed with E/M codes at the appropriate level of service based on the complexity of patient condition and diagnostic services rendered in the outpatient emergency department. It is based on coding principles established by the Centers for Medicare & Medicaid Services, and the CPT and HCPCS code descriptions.

What does this mean for facilities?

Blue Cross will review E/M claims that are billed with a Level 4 or 5 E/M code for the appropriate level of care on a prepayment basis. Claims that don’t meet the policy criteria will be adjusted and reimbursed at the appropriate level.

How will claims be reviewed?

An algorithm will be applied that takes three factors into account to determine a calculated visit level for the emergency department E/M services rendered. The three factors are:

1. Presenting problems – as defined by the ICD-10 reason for visit, or RFV, diagnosis
2. Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e., lab, X-ray, EKG/RT/other diagnostic, CT/MRI/ultrasound)
3. Patient complexity and co-morbidity – based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary and external cause of injury diagnosis codes

Applicable codes:

Facilities may experience adjustments to the Level 4 or 5 E/M codes submitted to reflect a lower E/M code calculated by the EDCA or may receive a denial for the code level submitted.

Facilities that are reimbursed for outpatient services on a percent of change basis, may rebill a denied Level 4 or 5 E/M code with a correct E/M code and the corresponding corrected charge in accordance with their chargemaster.

Exclusions

Claims that are for the following may be excluded from an adjustment or denial:

1. Patients who were admitted from the emergency department or transferred to another health care setting (skilled nursing facility, long-term care hospital, etc.)
2. Critical care patients (*99291, *99292)
3. Patients younger than 2 years of age
4. Certain diagnoses that, when treated in the emergency department, most often necessitate greater than average resource usage (for example, significant nursing time)
5. Patients who have died in the emergency department
6. Facilities billing Level 4 and 5 E/M codes that adhere to EDCA

You can find the Emergency Department Facility Evaluation and Management Coding policy on our provider portal, Availity^® Essentials, by logging in to availity.com,** selecting Payer Spaces in the menu bar and clicking on the BCBSM and BCN logo. Click on the Resources tab and then Secure Provider Resources (Blue Cross and BCN). In the menu bar, click on Billings and Claims and select Medical Policy.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.