Emergency Department Facility Evaluation and Management Coding Policy takes effect June 1

Blue Cross Blue Shield of Michigan began using the Optum Emergency Department Claims Analyzer, or EDCA, Jan. 4, 2023, after adoption through the Participating Hospital Agreement contract administration process. Last fall, we paused the program to continue discussions with health care providers about 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, we’ll begin using the EDCA again June 1, 2024, in conjunction with a new Emergency Department Facility Evaluation and Management Coding Policy. We developed this reimbursement policy to ensure that facilities are reimbursed based on the consistent coding that correctly describes a 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?

This policy will provide guidance for how Blue Cross will reimburse UB (facility) claims billed with evaluation and management, or E/M, codes at the appropriate level of service, based on the complexity of patient condition and diagnostic services provided in the outpatient emergency department. The policy is based on coding principles established by the Centers for Medicare & Medicaid Services and the CPT and HCPCS code descriptions.

What does this mean to facilities?

Blue Cross will initially review 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 provided. 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 (for example, lab tests; X-rays; EKG, RT or other diagnostic scans; CT, MRI or 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:

Facility claims may receive adjustments to the level 4 or 5 E/M codes submitted to reflect a lower E/M code calculated by the EDC analyzer or may receive a denial for the code level submitted. For those that are denied, facilities should review remittance information, as Blue Cross will indicate the appropriate E/M code for the claim to be accepted in accordance with the policy.

Facilities that are reimbursed for outpatient services on a percent of charge 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 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 under 2 years of age
4. Certain diagnoses that when treated in the ED most often necessitate greater than average resource use, such as significant nursing time
5. Patients who have died in the ED
6. Facilities billing level 4 and 5 E/M codes that adhere to EDCA

The Emergency Department Facility Evaluation and Management Coding Policy can be found on the Provider Resources website:

1. Log in to our provider portal, availity.com.**
2. Click Payer Spaces on the menu bar, and then click the BCBSM and BCN logo.
3. Click the Resources tab.
4. Click Secure Provider Resources (Blue Cross and BCN).
5. Click Billing and Claims on the menu bar, and then click Codes and Criteria.
6. Scroll down to the Clinical Editing section and click on Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy.

You can find additional information about the policy on the Provider Resources website.

**Blue Cross and BCN don’t own or control this website.