Anthem Blue Cross and Blue Shield Facility Reimbursement Policy Download

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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Subject: Emergency Department CT Policy Status: Active
Effective: 07/03/2013
Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or
products and policy criteria listed below.
Description
The Emergency Department (ED) is a hospital-owned location or department for the provision of unscheduled
episodic services to patients who present for immediate medical attention. Services rendered to a patient in the
ED usually do not exceed 24 hours.
Emergency Department level of service is determined by the intervention(s) that are performed in relationship
to the intensity of medical care required by the presenting symptoms and resulting diagnosis of the patient:
Straight Forward Complexity (99281/G0380): The presented 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.
Low Complexity (99282/G0381): 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.
Moderate Complexity (99283/G0382): 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.
Moderate-High Complexity (99284/G0383): 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.
High Complexity (99285/G0384): 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.
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Policy
The payment, if any, for Emergency Department (ED) Services is specified in the Plan Compensation
Schedule or Contract. The Health Plan requires that the patient’s medical record documentation for diagnosis
and treatment in the ED must indicate the presenting symptoms, diagnoses and treatment plan and requires a
written order by the physician clearly documented in the medical record.
A Current Procedural Terminology (CPT) ® Code or a Healthcare Common Procedure Coding System
(HCPCS) ® Code for Evaluation and Management (E&M) must be billed for the complexity of service that
occurred during the patient encounter at the ED. The Health Plan defines the complexity level of service for
the E&M codes as described in the table in Exhibit A, attached.
The table in Exhibit A provides criteria that The Health Plan will use to determine the level of reimbursement
as applicable for ED services. Exhibit A lists the E&M codes and defines the levels. Each level provides
procedure and clinical examples that align with the complexity level to assist the facility in understanding the
meaning of the descriptors used to define the level of E&M service. The procedure and clinical examples in
Exhibit A are not an all-inclusive list. The highest level E&M code for which a claim clinically qualifies will
be used to determine the level of reimbursement, as applicable for ED services.
Exhibit A
CPT® 99281/HCPCS® G0380
Straight Forward Complexity
The presented 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.
Procedure Examples
Clinical Examples
Triage only
Insect bite (uncomplicated)
No medication or treatment
Read Tb test
Wound Check-simple
Steri-Strip wound
Booster or follow up immunization--no acute injury
Dressing change (uncomplicated)
Prescription refill
Suture removal (uncomplicated)
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Exhibit A
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.
Procedure Examples
Clinical Examples
Simple trauma - no X-rays
Localized skin rash, lesion, sunburn
Cast removal
Minor viral infection
Epistaxis - no packing
Eye discharge - painless
Dental pain
Urinary frequency without fever
Basic specimen testing: Accucheck, dipstick, UA clean catch
Ear pain(otitis media, sinusitis, vertigo, swimmer's
ear, TMJ)
I&D of simple abscess
Assisting MD with any exam
Venipuncture of lab
Visual acuity exam
Simple cultures (throat, skin, urine, wound)
Simple laceration/abrasion repair (w/Dermabond, w/o sutures)
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 (1st or 2nd degree)
OTC medication administered
EKG
The procedure and clinical examples in Exhibit A are not an all-inclusive list. The highest level E&M code of which a
claim clinically qualifies will be used to determine the level of reimbursement, as applicable for ED services
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Exhibit A
CPT® 99283/HCPCS® G0382
Moderate Complexity
The presented problem(s) are of moderate severity. Head injury instructions, crutch training, bending, lifting, weightbearing 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.
Procedure Examples
Clinical Examples
Nebulizer treatment (2 or less)
Headache (Simple) - history of, no serial exam
Oxygen therapy
Head injury - without neurologic symptoms
Sprain - unable to bear weight
Cellulitis
Epistaxis with packing
Abdominal Pain (Simple)
Routine trach care
Minor trauma (with potential complicating factors)
Access port catheter
Medical conditions requiring prescription drug management
Heparin/saline lock
Fever which responds to antipyrectics
IV push medication
Eye pain (corneal abrasion or infection, blepharitis, iritis)
IV fluids without medication
Non-confirmed overdose
IM or Sub-Q medication administration
Mental Health - anxious, simple treatment
Ear or eye irrigation
Mild dyspnea - not requiring oxygen
Foley catheter insertion
GI bleed - fissure and hemorrhoid
Doppler assessment
Prescription Medication administer-PO
C-spine precautions
Fluorescein stain
Emesis/Incontinence care
Routine psych medical clearance
Limited social worker intervention
Prep or assist with procedures such as joint aspiration/injection, simple, fracture care etc
Post mortem care
X-ray of 2 or more body areas (not above and below joint of same limb)
Simple dislocation of patella, finger or toes w/o fracture
Assault without radiological testing
The procedure and clinical examples in Exhibit A are not an all-inclusive list. The highest level E&M code of which a
claim clinically qualifies will be used to determine the level of reimbursement, as applicable for ED services
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Exhibit A
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.
Procedure Examples
Clinical Examples
Blood transfusion
Headache - (Complex)
Pelvic exam
Head injury with LOC
Vaginal bleeding
Abdominal pain (Complex)
Nebulizer treatments - 3 or more
Chest Pain (Simple)
Insertion of nasal/oral airway
Respiratory Distress
Insertion of PEG or NG tube
Blunt/penetrating trauma with limited diagnostic testing
PICC Insertion
Headache with nausea and vomiting
Use of specialized resources – social services, hearing,
Dehydration requiring treatment
visual impairment, police, crisis management
Special imaging study (CT,MRI, Ultrasound, VQ scan)
Dyspnea with oxygen treatment
Cardiac monitoring
Chest pain with limited diagnostic testing
Administration and monitoring of infusion or parental
Neurological symptoms: slurred speech, staggered walking,
medications (IV, IM,IO, SC)
paralysis or numbness of face, arm or leg, or blurred vision
in one or both eyes.
Insertion of NG or PEG tube placement, or replacement
with multiple reassessments
Irrigation of eye with Morgan lens
Irrigation of bladder with 3-way foley catheter
Sexual assault exam with specimen collection
Psychotic patient - not suicidal
Change trach tube
EKG x 2 or more
Care of a confused, combative patient
Change in mental status of patient
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield
Facility Reimbursement Policy
Exhibit A
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.
Procedure Examples
Clinical Examples
Cardiac monitoring
Chest pain - Cardiac
Multiple IVS
Active GI bleed - excluding fissure and hemorrhoid
Admit to ICU
Severe respiratory distress
Suicide watch
Epistaxis (Complex)
Physical or chemical restrains
Blunt/penetrating trauma with multiple diagnostic testing
Coordination of hospital admission, transfer or change in
Systemic multi-system medical emergency requiring
living situation or site
multiple diagnostics
Fracture reduction or relocation
Severe infections requiring IV/IM antibiotics
Endotracheal or trach tube insertion
Uncontrolled diabetes - Blood sugar level at 300 or higher
and exhibiting complications like DKA and or unstable
vital signs or HHNK
Endoscopy
Severe burns - (Level 3 or 4)
Thoracentesis or paracentesis
Hypothermia
Conscious sedation
New onset altered mental status
Decontamination for isolation, hazardous material
Headache (severe) requiring CT and/or Lumbar puncture
Precipitous delivery in ER
Major musculoskeletal injury
Acute peripheral vascular compromise of extremities
Toxic ingestions
Suicidal or homicidal
CPT® is a registered trademark of the American Medical Association
Use of Reimbursement Policy:
This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member’s benefits on the
date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, or otherwise, without permission from Anthem Blue Cross and Blue Shield.
©2016 Anthem Blue Cross and Blue Shield
Emergency Department
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Connecticut Inc.
Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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