Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Criteria for Reimbursement of Emergency Room Services

Policy #:00.10.03j



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Services that are performed in the emergency room (ER)/emergency department (ED) setting are reimbursed to participating professional providers and/or to the participating facility in which the services are provided. The Company applies the definition of emergency and diagnostic criteria to determine the appropriate level of reimbursement for these services.

In accordance with the facility and/or professional provider contracts, the following reimbursement methodologies may be applied to facility claims and claims submitted by professional providers who specialize in emergency medicine:
  • Eligible emergent services may be reimbursed at an emergency level.
  • Eligible services that are not considered emergent may be reimbursed at a triage level (i.e., a reduced rate).

For all other Company products, medically necessary ER/ED services are covered and eligible for reimbursement consideration as outlined in the applicable participating professional provider contract or participating facility contract.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, Emergency Room Services are covered under the medical benefits of the Company's products.

Description

    EMERGENCY LEVEL

    Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting to participating professional providers and/or to participating facilities is based on diagnostic criteria, the definition of emergency, and all applicable facility provider and/or professional provider contract terms.

    Emergency is defined as the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any one of the following:
    • The health of the individual being placed in serious jeopardy
    • The health of a pregnant woman or her unborn child being placed in serious jeopardy
    • Serious impairment to the individual's bodily functions
    • Serious dysfunction of any of the individual's bodily organs or parts

    Medical emergency situations include, but are not limited to:
    • Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions
    • Accidents such as, but not limited to, falls, severe cuts, broken bones, and other traumatic bodily injuries

    TRIAGE LEVEL

    When the individual's condition does not meet diagnostic criteria or the definition of emergency, the participating facility and/or participating professional provider, in accordance with the applicable provider contract, may receive a reduced level of reimbursement. This reduced level of reimbursement is referred to as a triage rate or triage level of reimbursement.

    References

    Centers for Medicare & Medicaid Services (CMS). Emergency Medical Treatment and Labor Act Technical Advisory Group (EMTALA TAG).[CMS Web site]. 03/26/2012. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/. Accessed January 28, 2020.


    Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual
    Chapter 4 - Benefits and Beneficiary Protections: 20.2 – Definitions of Emergency and Urgently Needed Services. [CMS Web site]. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed January 28, 2020.

    Commonwealth of Pennsylvania. Title 28: Health and Safety. Part I: General Health. 9.602: Definitions, emergency service. [The Pennsylvania Code Web site]. 06/09/01. Available at: http://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed January 28, 2020.

    Commonwealth of Pennsylvania. Title 28: Health and Safety. Part VII: Emergency Medical Services. 1001.2: Definitions, emergency medical services (EMS). [The Pennsylvania Code Web site]. 02/07/04. Available at: http://www.phila.gov/regionalems/PDF/RULESANDREGULATIONS.pdf. Accessed January 28, 2020.

    Company Benefit Contracts

    Company Provider Manuals

    New Jersey Department of Banking and Insurance. Health Insurance Programs: Individual Health Coverage Programs. Small Employer Benefits Programs. [New Jersey Department of Banking and Insurance Web site]. Available at: http://www.state.nj.us/dobi/reform.htm. Accessed January 28, 2020.

    New Jersey Legislature. Assembly Health Committee Statement To Assembly, Bill No. 2829. [New Jersey Legislature Web site]. 02/23/2015. Available at: http://www.njleg.state.nj.us/2014/Bills/A3000/2829_S3.PDF. Accessed January 28, 2020.



    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

99281, 99282, 99283, 99284 , 99285, 9929, 99292


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)


0450 Emergency Room - General

0451 Emergency Room - EMTALA Emergency Medical Screening Services

0452 Emergency Room - ER Beyond EMTALA

0456 Emergency Room - Urgent Care

0459 Emergency Room - Other Emergency Room

0681 Trauma Response - Level I

0682 Trauma Response - Level II

0683 Trauma Response - Level III

0684 Trauma Response - Level IV

0689 Trauma Response - Other Trauma Response

0981 Professional Fees - Emergency Room



Coding and Billing Requirements



Policy History

03/23/2020Effective 3/23/2020 policy number 00.10.03j was issued as a result of annual policy update.

The Required Documentation criteria has been added to the "policy" section.

The following CPT code narratives were revised in this policy to reflect current Current Procedural Terminology and American Medical Association guidelines: 99281, 99282, 99283, 99284, and 99285.

CPT code 99288 has been deleted from this policy.
    10/05/2017Effective 10/05/2017 this policy has been updated to the new policy template
    format.
    Version Effective Date: 03/23/2020
    Version Issued Date: 03/23/2020
    Version Reissued Date: N/A



2017 AmeriHealth.