Review of professional claims with emergency department level 5 E&M codes

Category: Medicaid

Empire BlueCross BlueShield HealthPlus (Empire) has identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, Empire will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

Empire will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Empire guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for nonemergencies, nor do they include the examination of emergent versus nonemergent reasons patients utilize emergency room services.