Emergency Department (ED) Outpatient Facility Evaluation and Management (E/M) Coding Policy

Date: 05/30/19

As part of our continued efforts to reinforce accurate coding practices, Magnolia Health Plan will implement the following new Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement policy and procedure.  This policy applies to the following lines of business as of the dates shown below:

•         MSCAN, effective July 1, 2019

•         CHIP, effective July 1, 2019

•         Ambetter, effective July 1, 2019

•         Allwell, effective July 1, 2019

This policy focuses on outpatient facility ED claims that are submitted with level 1 (99281, G0380), level 2 (99282, G0381), level 3 (99283, G0382), level 4 (99284, G0383), or level 5 (99285, G0384) E/M codes. This policy was developed using our national experience to address inconsistencies in coding accuracy and is 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.

This policy will apply to all facilities, including freestanding facilities, that submit ED claims with level 1, 2, 3, 4, or 5 E/M codes for members of the affected lines of business, regardless of whether they’re under contract to participate in our network.

The implementation of this policy is in an effort to comply with the CMS Informational Bulletin dated 1/16/14 with the subject:

Reducing Nonurgent Use of Emergency Departments and Improving Appropriate Care in Appropriate Settings

To learn more click the links below.

Emergency Department (ED) Outpatient Facility Evaluation and Management (E/M) Coding Policy (PDF)

Excluded Diagnosis by EDC Analyzer (PDF)