Straightforward
Self-limited condition with no meds or home treatment required, signs and symptoms of wound infection explained, return to Emergency Department (ED) if problems develop (see Reference section, #1).
Simple
Over the counter (OTC) medications or treatment, simple dressing changes; patient demonstrates understanding quickly and easily (see Reference section, #1).
Moderate
Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration.
Complex
Multiple prescription medications and/or home therapies with review of side effects and potential adverse reactions; diabetic, seizure or asthma teaching in compromised or non-compliant patients; patient/caregiver may demonstrate difficulty understanding instructions and may require additional directions to support compliance with prescribed treatment.
Emergency Department
- Type A emergency department: must meet regulatory requirements and be open 24 hours/day and 7 days/week and apply codes 99281-99285.
Type B emergency department: must meet regulatory requirements but is not open 24 hours/day and 7 days/week and apply codes G0380-G0384.
Emergency Medical Condition
- Member is in serious jeopardy of their health or their unborn child, or
- Has serious body function or impairment, or
Has serious dysfunction of any bodily organ or part.
Emergency Services
Services needed to stabilize an emergency medical condition.
Background
Currently, there are no national standards, that assign levels of services in the emergency department (ED). Thus, the American College of Emergency Physicians (ACEP) developed emergency department (ED) level guidelines, which are in line with the outpatient prospective payment system (OPPS) principles (see Reference section, #1). The ACEP guideline is one of the best-known models for assessing the appropriate level of ED services. The level of care is determined by interventions/complexity of services. Even if multiple interventions within a level occur, the level is the same e.g., two or three interventions within the 99281 level would remain as a 99281 level.
Note: This policy has been revised. The revised policy will be effective 11/1/2024. To view the revised policy, click here
Individual facility provisions, contracts or state or federal guidelines take precedence over this policy.
Reimbursement for facility Emergency Department (ED) services are based on the highest-level E&M and revenue code for which a claim qualifies. A Current Procedural Terminology (CPT®) Code or a Healthcare Common Procedure Coding System (HCPCS) Code for Evaluation and Management (E&M) must be billed, based on the complexity of facility intervention(s) that occurred, during the patient ED visit.
Our health plan requires documentation from the ED visit that includes but is not limited to physician order(s), presenting symptoms, diagnoses and treatment plan in the medical record.
Our health plan reviews the complexity level of facility interventions for the E&M codes as described in the table below. Each level provides facility intervention examples that align with the evaluation and management (E&M) service. The table below, although not an all-inclusive, provides criteria that our health plan will apply to determine the level of reimbursement, for ED services.
Exceptions include:
- ED visits resulting in observation status or inpatient admission. Emergency Room visits that result in an Inpatient submission will follow guidelines under Reimbursement of Facility Room and Board policy (FAC 103)
- Critical access hospital services
- Trauma or critical care services
Surgical intensive care services
If a member is admitted as an inpatient from the emergency department or from observation following a visit to the emergency department, the emergency department services provided to that member must be submitted on the same claim as the inpatient services and are not subject to this policy.
Level | Description | Facility Intervention Examples | Clinical Examples |
|---|---|---|---|
| |||
99281 (G0380) | Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional. |
|
|
99282 (G0381) | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. |
|
|
99283 (G0382) | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low medical-decision making. |
|
|
99284 (G0383) | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate medical decision-making. |
|
|
99285 (G0384) | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high medical decision-making. | Any interventions from above, plus any below:
|
|
American College of Emergency Physicians (ACEP), ED Facility Level Coding Guidelines
Anthem Emergency Department: Level of Evaluation and Management Services
Optum360, 2020
Centers for Medicare and Medicaid Services (CMS), 42 CFR § 422.113
Centers for Medicare and Medicaid Services (CMS), OPPS Visit Codes Frequently Asked Questions, CMS.gov
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.