This document provides coding and billing guidelines for Emergency Department Providers (facilities and physicians or other qualified health care professionals (QHPs)) to ensure the code(s) billed meet the coding requirements.
Coding & Billing Guidelines
Emergency Department (ED) Evaluation and Management (E/M) codes are typically reported per day and do not differentiate between new or established patients. There are 5 levels of emergency department services represented by CPT codes 99281 – 99285. The ED codes require the level of Medical Decision Making (MDM) to be met and documented for the level of service selected.
Note: Per the American Medical Association (AMA), time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.
CMS-1500 Claim Form
- Place of Service (POS): 23 – Professional claims; ED visit E/M codes are restricted to the emergency POS.
UB04 Claim Form
- Revenue Code: 0450 – Emergency Room – General
The level of service billed must be based on the intervention(s) that are performed in relationship to the medical care required by the presenting symptoms and resulting in diagnosis of the patient. Professional codes are based on complexity, performed work, which includes the “cognitive” effort. Facility codes reflects volume and intensity of resources used by the facility to provide care.
Medical records and documentation may be requested from the provider to support the level of care rendered. The documentation must clearly identify, and support ED E/M codes billed. If a denial is appealed, the supporting documentation must be included in the appeal request.
The tables below provide criteria that Blue Cross Blue Shield of North Dakota (BCBSND) will use to determine the appropriate code application for ED services.