Emergency Department (ED) Outpatient Facility Evaluation and Management (E/M) Coding Policy

As part of our continued efforts to reinforce accurate coding practices, BCBSRI is adding an Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement policy.

This policy focuses on outpatient facility ED claims that are submitted with level 1 (99281), level 2 (99282), level 3 (99283), level 4 (99284), or level 5 (99285) E/M codes. This policy was developed to address inconsistencies in coding accuracy and were based on the E/M coding principles created by the Centers for Medicare and Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT® code descriptions and reasonably relate to hospital resource use. 

This policy will apply to all facilities, including freestanding facilities, which submit ED claims with level 1, 2, 3, 4, or 5 E/M codes.

As part of the implementation of these policies and procedures, BCBSRI will begin reviewing appropriate E/M coding levels based on data from the patient’s claim including the following: 

• Patient’s presenting problem
• Diagnostic services performed during the visit
• Any patient complicating conditions

Facilities submitting claims for ED E/M codes may experience adjustments to level 1, 2, 3, 4, or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial. Facilities will have the opportunity to submit appeal requests if they believe a higher-level E/M code is justified.

Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

• Claims for patients who were admitted from the emergency department or transferred to another healthcare setting (skilled nursing facility, long-term care hospital, etc.)
• Claims for patients who received critical care services (99291, 99292)
• Claims for patients who are under the age of two years
• Claims with certain diagnosis codes that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
• Claims for patients who passed in the ED

Ultimately, the mutual goal of facility coding is to accurately capture ED resource utilization and align that with the E/M CPT® code description for a patient visit per CMS guidance.

For additional details related to this policy, please click here.

Prepayment change effective July 2024   PBF

BCBSRI is committed to continuously improving payment integrity to prevent overpayments due to waste or abuse. Effective July 2024, BCBSRI will begin performing additional prepayment claim reviews utilizing Optum’s Comprehensive Payment Integrity (CPI) tool, which ensures that claims are processed and paid accurately. As a result of these reviews, providers may be asked for medical records and billing documents that support the charges billed. After medical records are reviewed, the claim is processed to be paid, if the documentation supports the claim as billed.

BCBSRI utilizes widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. Prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. Documentation to support the diagnosis and services/supplies billed must be present in the medical record.

If requested, providers will receive detailed instructions about how to submit the documentation. If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to appeal results of reviews. 

For additional details related to this policy, please click here. 

2024 preventive services for commercial and Medicare Advantage plan members 

A new product for colorectal screening is Colosense Plus® HCPCS code 0646U. This HCPCS code will be effective July 1, 2024. This newer product falls under the preventive services taskforce recommendations for colorectal cancer screening. Therefore, this product is to be added to both the commercial and Medicare preventive policies. For additional details related to this policy, please click here for Medicare and here for commercial.