AdministrativeCommercialApril 1, 2024

Emergency department protocol for Special Investigation Unit review

Anthem uses post-pay and prepayment review in certain circumstances to validate the appropriate level for facility emergency department (ED) claims. This process identifies the level of ED E&M code by intensity and/or complexity of resources or interventions a facility uses to furnish all services indicated on the claim. Providers must use appropriate HIPAA-compliant codes for all services rendered during the ED encounter. The highest intervention/resource used will determine the final facility ED level.

Anthem defines:

  • Interventions: the staff the facility uses and their work performed
  • Resources: facility building, equipment, and/or supplies used
  • Note: Professional provider services are not considered facility interventions or resources.
  • Intensity and/or complexity: quantity, type, or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity, and diagnostic services performed, as indicated on the claim
  • Emergency services: a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care, could result in (a) placing the health of an individual in serious jeopardy, (b) serious impairment to bodily function, (c) serious dysfunction of any bodily organ or part, (d) serious disfigurement, or (e) in the case of a pregnant woman, serious jeopardy to the health of the woman or her unborn child

** In the event a determination cannot be made based on the guidance in this document, a referral to a medical director for a determination will be made.

CPT® 99281/HCPCS G0380

Straight forward complexity

The presenting problem(s) are self-limited or minor conditions with no medications or home treatment required, signs and symptoms of wound infection explained, return to ED if problems develop.

Facility intervention

Clinical examples

Triage only

Insect bite (uncomplicated)

No medication or treatment

Read Tb test

Wound recheck

Steri-Strip wound

Booster or follow up immunization—no acute injury

Dressing change (uncomplicated)

Prescription refill

Suture removal (uncomplicated)

CPT 99282/HCPCS G0381

Low complexity

The presented problem(s) are of low to moderate severity. Over the counter (OTC) medications or treatment, simple dressing changes; patient demonstrates understanding quickly and easily.

Facility intervention

Clinical examples

Simple trauma — up to one x-ray procedure

Localized skin rash, lesion, sunburn

Cast removal

Minor viral infection

Visual acuity exam (Snellen)

Eye discharge — painless

Basic specimen testing: Accucheck, dipstick, UA clean catch

Urinary frequency without fever

I&D of simple abscess

Ear pain (otitis media, sinusitis, vertigo, swimmer's ear, TMJ)

Venipuncture of lab

Dental pain

Simple cultures (throat, skin, urine, wound)

Epistaxis — no packing

Simple laceration/abrasion repair (with Dermabond, without sutures)

Assisting MD with any exam

Simple removal of foreign body without incision or anesthetic

Apply ace wrap or sling

Prep or assist with procedures such as minor laceration repair

Simple burn treatment (first or second degree)

OTC medication administered

EKG

CPT 99283/HCPCS G0382

Moderate complexity

The presented problem(s) are of moderate severity. Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration.

Facility intervention

Clinical examples

Nebulizer treatment (two or less)

Headache (simple) — history of, no serial exam

Oxygen therapy

Head injury - without neurologic symptoms

Access port catheter

Cellulitis

Heparin/saline lock

Abdominal pain (simple)

IV push medication

Minor trauma (with potential complicating factors)

IV fluids without medication

Medical conditions requiring prescription drug management

IM or Sub-Q medication administration

Fever which responds to antipyretics

Ear or eye irrigation

Eye pain (corneal abrasion or infection, blepharitis, iritis)

Foley catheter insertion

Non-confirmed overdose

Doppler assessment

Mental health — anxious, simple treatment

Prescription medication administer — PO

Mild dyspnea - not requiring oxygen

Fluorescein stain

Fissure or hemorrhoid

Prep or assist with procedures such as joint aspiration/injection, simple, fracture care, etc.

Epistaxis with packing

X-ray of two or more body areas or two or more x-ray procedures (not above and below joint of same limb)

Assault without radiological testing

Psychotic patient with no imminent danger to self or others which includes social worker or behavioral health clearance.

Emesis/Incontinence care

Postmortem care

Simple dislocation of patella, finger, or toes without fracture

Sprain — unable to bear weight

Routine trach care

CPT 99284/HCPCS G0383

Moderate-high complexity

The presented problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration.

Facility intervention

Clinical examples

Blood transfusion

Headache — (complex) or with nausea and vomiting

Insertion of nasal/oral airway

Head injury with LOC

Special imaging study (CT, MRI, Ultrasound, VQ scan)

Chest pain (simple) or with limited diagnostic testing

Cardiac monitoring (external)

Respiratory distress

Administration and monitoring of infusion or parental medications (IV, IM, IO, SC) (Not for immunization administration)

Blunt/penetrating trauma with limited diagnostic testing

Insertion of NG or PEG tube placement, or replacement with multiple reassessments

Dehydration requiring treatment

Prep or assist with procedures such as” Irrigation of eye with Morgan lens, complex laceration repair

Dyspnea with oxygen treatment

Irrigation of bladder with three-way foley catheter

Neurological symptoms: slurred speech, staggered walking, paralysis or numbness of face, arm or leg, or blurred vision in one or both eyes

Change trach tube

Psychotic patient requiring medications in ED with no imminent danger to self or others

EKG x two or more

Care of a confused, combative patient

Change in mental status of patient

CPT 99285/HCPCS G0384

High complexity

The presented problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Multiple prescription medications and/or home therapies with review of side effects and potential adverse reactions; diabetic, seizure, or asthma teaching in compromised or non-compliant patients; patient/caregiver may demonstrate difficulty understanding instructions and may require additional directions to support compliance with prescribed treatment.

Facility intervention

Clinical examples

Cardiac monitoring (invasive)

Chest pain (cardiac)

Multiple IV administrations, does not include fluid administration, and at least one diagnostic imaging study with IV contrast.

Active GI bleed — excluding fissure and hemorrhoid

Physical or chemical restraints

Severe respiratory distress

Fracture reduction or relocation

Epistaxis (complex)

Endotracheal or trach tube insertion

Blunt/penetrating trauma with multiple diagnostic testing required

Endoscopy

Systemic multi-system medical emergency requiring multiple diagnostics

Thoracentesis or paracentesis

Severe infections requiring IV/IM antibiotics

Conscious sedation

Uncontrolled diabetes — blood sugar level at 300 or higher and exhibiting complications like DKA and or unstable vital signs or HHNK

Decontamination for isolation, hazardous material

Severe burns — (level 3 or 4)

Precipitous delivery in ER

Hypothermia

Nebulizer treatments — three or more (If Nebulizer is continuous, each 20-minute period is considered one treatment)

New onset altered mental status

PICC Insertion

Headache (severe)

Lumbar puncture

Major musculoskeletal injury

Sexual Assault Exam with specimen collection by ED staff

Acute peripheral vascular compromise of extremities

Coordination of hospital admission (inpatient or observation) or transfer or change in living situation or site

Toxic ingestions

More than one imaging study (CT, MRI, Ultrasound, VQ scan) combined with multiple different types of departmental tests (lab, EKG, x-ray)

Suicidal or homicidal patient with risk to self or others

Elevated D-dimer that leads to single special imaging study, for example, CT scan

Sexual assault exam with specimen collection

Abdominal pain (complex)

Reference and research material

Developed through the consideration of the American College of Emergency Physicians ED Facility Level Coding Guidelines. Revised: April 14, 2022

For specific administrative policy details, visit anthem.com/provider/forms and select your state. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: April 2024 Provider Newsletter