Revised coding policies for Emergency Department outpatient facility Evaluation and Management

September 18, 2024

As part of our continued efforts to reinforce accurate coding practices, we are revising the current Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement policies and procedures. This revision applies to all plans and lines of business as of January 1, 2025.

For claims submitted with levels 3-5 codes

The revision focuses on outpatient facility ED claims that are submitted with level 3 (99283, G0382), level 4 (99284, G0383), or level 5 (99285, G0384) E/M codes.

The policy revisions are based on the E/M coding principles created by the Centers for Medicare and Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT® code descriptions and reasonably relate to hospital resource use.

These policies will apply to all facilities, including freestanding facilities, that submit ED claims with level 3, 4, or 5 E/M codes for members of the affected plans, regardless of whether they’re under contract to participate in our network.

The Optum EDC Analyzer™ tool

As part of the implementation of these policies and procedures, we’ll begin using the Optum Emergency Department Claim (EDC) Analyzer tool, which determines appropriate E/M coding levels based on data from the patient’s claim including the following:

Patient’s presenting problem
Diagnostic services performed during the visit
Any patient complicating conditions

Learn more about the EDC Analyzer tool by downloading the Emergency Department Claim Analyzer Guide (PDF).

Adjustments to codes

Facilities submitting claims for ED E/M codes may experience adjustments to level 3, 4, or 5 E/M codes to reflect an appropriate level E/M code based on the reimbursement structure within their contracts with us. Facilities will have the opportunity to submit reconsideration or appeal requests if they believe a higher level E/M code is justified, in accordance with the terms of their contract.

Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

Claims for patients who were admitted from the emergency department or transferred to another health care setting (Skilled Nursing Facility, Long Term Care Hospital, etc.)
Claims for patients who received critical care services (99291, 99292)
Claims for patients who are under the age of 2 years
Claims with certain diagnosis codes that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
Claims for patients who expired in the ED