Skip to main content
Shop Plans Learn more about our coverage options including health, Medicare, dental and vision options for you, your family or your employees. Get Started Individual & Family Medicare Employer Vision Dental International Travel Find Care FAQ Blog Members Stay on top of your health care with helpful member resources. Members Home Medicare Health Dental Vision Find Care Member Knowledge Center Member Forms Medicare Forms Library Make a Payment Federal Employees Student Blue Healthy Blue Providers Access tools, policies and the latest information to help you care for our members. Providers Home Network Participation Networks & Programs Claims, Appeals & Inquiries Prior Authorization Services & CPT codes Prescription Drug Search Policies, Guidelines & Codes Provider News Provider FAQ Contact Us Employers Learn about our coverage options for small and large employers, and access tools and resources for your group. Employers Home Shop Employer Plans Employer Portal Support Member Forms & Resources Find Care Blog Agents Access the tools you need: rate quotes, applications, forms, the latest industry news, marketing materials and more. Agents Home Agent Services Check Eligibility Find Care Member Forms & Resources Medicare Forms Library
Contact Us
Log In
I am ... Please select A member A provider An employer An agent
Log in to Agent Services
Log in to Employer Services Register for Employer Services I'm registered but need portal access
Username Forgot username? Continue to Log In Register for Blue Connect Need help? Learn how to log in.
Log in to Blue e Register for Blue e Log in to Dental Blue
Back
Facility Emergency Department E&M Services

Commercial Reimbursement Policy

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 EncounterInterventionsResources
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. 

Disclosures:

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.

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.

Information in other languages: Español   中文   Tiếng Việt   한국어   Français   العَرَبِيَّة   Hmoob   ру́сский   Tagalog   ગુજરાતી   ភាសាខ្មែរ   Deutsch   हिन्दी   ລາວ   日本語

© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.