Reimbursement Policy Update: Emergency Department: Leveling of Evaluation and Management Services (Facility)

Effective January 1, 2021, Empire BlueCross BlueShield (“Empire”) classifies with an Evaluation and Management (E&M) code level the intensity/complexity of emergency department (ED) interventions a facility utilizes to furnish all services indicated on the claim.  E&M services will be reimbursed based on this classification. Facilities must utilize appropriate HIPAA compliant codes for all services rendered during the ED encounter. If the E&M code level submitted is higher than the E&M code level supported on the claim, we reserve the right to perform one of the following:

• Deny the claim and request resubmission at the appropriate level or request the provider submit documentation supporting the level billed
• Adjust reimbursement to reflect the lower ED E&M classification
• Recover and/or recoup monies previously paid on the claim in excess of the E&M code level supported

 

Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details at empireblue.com. Please include this update with your Provider Manual for future reference. 

 

Facilities that believe their medical record documentation supports reimbursement for the originally submitted level for the E&M service will be able to follow the dispute resolution process in accordance with the terms of their contract. Claims disputes require a statement providing the reason the intensity/complexity would require a different level of reimbursement and the medical records which should clearly document the facility interventions performed and referenced in that statement.

 

692-1020-PN-NY