Commercial Reimbursement Policy
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Origination: 03/2024
Last Review: 03/2024
Description
Interventions are the preparation, assistance, and/or facilitation of services performed by nursing and ancillary facility staff during an Emergency Department (ED) encounter.
Resources are the room(s), supplies, equipment, staff and facility resources utilized to provide care during an ED encounter.
Intensity and/or complexity is the degree of specialization, involvement, quantity, time frame, or type of facility resources and/or interventions utilized during an ED encounter.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) reimburses facility ED evaluation and management (E&M) services based on the appropriate alignment with the intensity and complexity of facility resources expended, in accordance with the criteria outlined in this policy.
Reimbursement Guidelines
Blue Cross NC assesses the intensity and/or complexity of facility interventions and resources expended based on the services rendered during the facility ED E&M visit. The following categories will be assessed in determining the intensity and/or complexity of facility interventions and resources provided for the ED E&M services:
- Radiology and other diagnostic tests (simple radiology, specialized radiology, device interrogation, EKG/ECG/EEG, etc.)
- Simple Procedures (PICC line, endoscopy, lumbar puncture, intravenous care and/or insertions, etc.)
- Assessment/Exams (pelvic, neurological, visual, etc.)
- Nursing Care (routine care, continuous monitoring, respiratory interventions, continuous bedside presence/care)
- Specialized Interventions (case management, complex transfer coordination, Ambulance, etc.)
- Straightforward or Moderate Trauma (wound care, fractures, dislocations, burns, etc.)
- Complexity of presenting problems and/or co-morbidities
Providers must submit on their claim all services rendered and resources expended during the encounter via comprehensive Health Insurance Portability and Accountability Act (“HIPAA”) compliant coding. The E&M code submitted must align with the intensity and complexity of interventions and resources expended for that encounter level. The table below details criteria that Blue Cross NC uses to determine the appropriate code application for ED E&M services.
| ED Encounter | Interventions | Resources |
|---|---|---|
| Level 1 (Straightforward) 99281 | Minor Minimal involvement of facility staff | Minimal Smallest quantity needed of facility resources |
| Level 2 (Low) 99282 | Low Complexity Non-specialized, scoped facility staff involvement | Limited Scoped use of facility resources |
| Level 3 (Moderate) 99283 | Moderate Complexity Non-specialized, yet evolving and/or time-consuming facility staff involvement | Moderate Multiple use of simple, nonspecialized resources |
| Level 4 (Moderate-High) 99284 | High Complexity Specialized facility staff involvement | Limited Intensive Use of specialized resources |
| Level 5 (High) 99285 | Extreme Complexity Specialized, high level of facility staff involvement | Intensive Multiple use of specialized resources |
If facility resources expended during the ED encounter do not align with the E&M service billed, the claim may be denied. Blue Cross NC reserves the right to request medical records and/or itemized bills in determination of reimbursement and/or recovery or recoupment of previously paid claims in excess of the E&M code level supported.
Exclusions
This policy does not apply to professional ED E&M services. Additionally, facility ED E&M services that involve the following scenarios are excluded from this policy:
- Primary diagnosis of a psychiatric disease
- Members under the age of 2
- Members that expire in the ED
- Admission to inpatient or observation status
- Maternity care
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
| CPT® / HCPCS Code / Modifier | Explanation |
|---|---|
| 99281 G0380 | Resources and interventions used by the facility to provide care for presenting problem(s) that are self-limited or minor conditions |
| 99282 G0381 | Resources and interventions used by the facility to provide care for presenting problem(s) that are of low to moderate severity |
| 99283 G0382 | Resources and interventions used by the facility to provide care for presenting problem(s) that are of moderate severity |
| 99284 G0383 | Resources and interventions used by the facility to provide care for presenting problem(s) that are of moderate to high severity and require urgent evaluation |
| 99285 G0384 | Resources and interventions used by the facility to provide care for presenting problem(s) that are of high severity and pose an immediate significant threat to life or physiologic function |
Related Policy
Diagnosis Validity and Code Guidelines
Facility Billing Guidelines
Pricing and Adjudication Principles
References
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
Health Insurance Portability and Accountability Act of 1996
American College of Emergency Physicians (ACEP)
History
3/1/2024 New Policy. RPOC Approved. Notification on 3/1/2024 for effective date 5/1/2024 (ss)
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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