CommercialOctober 31, 2023
Emergency Department Post-Pay Review Protocol
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
Empire BlueCross BlueShield (Empire) utilizes post-pay review in certain circumstances to validate the appropriate level for facility emergency department claims. This process identifies the level of ED E&M code by intensity and/or complexity of resources or interventions a facility utilizes to furnish all services indicated on the claim. Providers must utilize appropriate HIPAA-compliant codes for all services rendered during the ED encounter. The highest intervention/resource used will determine the final facility ED level.
Empire 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 |
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Steri-Strip wound |
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Booster or follow up immunizatio—no acute injury |
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Dressing change (uncomplicated) |
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Prescription refill |
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Suture removal (uncomplicated) |
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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 |
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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) |
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Simple laceration/abrasion repair (w/Dermabond, w/o sutures) |
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Simple removal of foreign body without incision or anesthetic |
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Apply ace wrap or sling |
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Prep or assist with procedures such as minor laceration repair |
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Simple burn treatment (first or second degree) |
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OTC medication administered |
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EKG |
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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 |
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
NYBCBS-CM-040236-23
PUBLICATIONS: November 2023 Provider Newsletter
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