Notification



Notification Issue Date:

The new Medicare Advantage policy portfolio that includes this policy bulletin will become effective on 01/01/2015.



Medicare Advantage Policy

Title:Criteria for Reimbursement of Emergency Room Services
Policy #:MA00.044a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Services that are performed in the emergency room (ER)/emergency department (ED) setting are reimbursed to participating professional providers and/or to the participating facility in which the services are provided. The Company applies the definition of emergency and medical necessity criteria to determine the appropriate level of reimbursement for these services.

In accordance with the facility or provider contract the follow payment methodologies may be applied to facility claims and to claims submitted by providers who specialize in emergency medicine:
  • Eligible services are reimbursed at an emergency level
  • Reimbursement may be considered at a reduced level (e.g., triage rate)

Individual provider contracts must be verified. In such cases, facilities or providers are notified of the Provider Appeals Process and its requirements.

For all other Company products, medically necessary ER/ED services are covered and eligible for reimbursement consideration as outlined in the applicable participating professional provider contract or participating facility contract.

Policy Guidelines

This policy is consistent with Medicare's coverage determination for this service. The Company's payment methodology may differ from Medicare.

Description

Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting by participating professional providers and/or to participating facilities is based on medical necessity. A medical necessity determination is made using diagnostic criteria, the definition of emergency, and all applicable facility provider, professional provider, and/or member contract terms.

Emergency is defined as the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any one of the following:
  • The health of the individual being placed in serious jeopardy
  • The health of a pregnant woman or her unborn child being placed in serious jeopardy
  • Serious impairment to the individual's bodily functions
  • Serious dysfunction of any of the individual's bodily organs or parts

Medical emergency situations include, but are not limited to:
  • Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions
  • Accidents such as, but not limited to, falls, severe cuts, broken bones, and other traumatic bodily injuries

When the individual's condition does not meet medical necessity diagnosis criteria and/or the definition of emergency, the participating facility and/or participating professional provider, in accordance with the applicable provider contract, may receive a reduced level of reimbursement. This reduced level of reimbursement is referred to as a triage rate or triage level of reimbursement.

References

Centers for Medicare & Medicaid Services (CMS). Emergency Medical Treatment and Labor Act Technical Advisory Group (EMTALA TAG).[CMS Web site]. 03/26/2012. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA/. Accessed September 1, 2015.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Part II: Department of Health and Human Services CMS. Clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions. [CMS Web site]. 03/30/2007. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/Transplantfinal.pdf. Accessed September 1, 2015.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections: 20.2 – Definitions of Emergency and Urgently Needed Services. [CMS Web site]. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed September 1, 2015.

Centers for Medicare & Medicaid Services (CMS). Medlearn Matters (MM).MM #5427: Services Not Provided Within United States.[CMS Web site]. 8/24/2012. Available at:
https://www.cms.gov/MLNMattersArticles/downloads/MM3781.pdf . Accessed September 1, 2015.

Centers for Medicare & Medicaid Services (CMS). MLN Matters: Services Not Provided Within United States. [CMS Web site]. 2/23/2007. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R66BP.pdf. Accessed September 1, 2015.

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part I: General Health. 9.602: Definitions, emergency service. [The Pennsylvania Code Web site]. 06/09/01. Available at: http://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed September 1, 2015.

Commonwealth of Pennsylvania. Title 28: Health and Safety. Part VII: Emergency Medical Services. 1001.2: Definitions, emergency medical services (EMS). [The Pennsylvania Code Web site]. 02/07/04. Available at: http://www.phila.gov/regionalems/PDF/RULESANDREGULATIONS.pdf. Accessed September 1, 2015.

New Jersey Department of Banking and Insurance. Health Insurance Programs: Individual Health Coverage Programs. Small Employer Benefits Programs. [New Jersey Department of Banking and Insurance Web site]. Available at: http://www.state.nj.us/dobi/reform.htm. Accessed September 1, 2015.

New Jersey Legislature. Assembly Health Committee Statement To Assembly, Bill No. 2829. [New Jersey Legislature Web site]. 02/23/2015. Available at: http://www.njleg.state.nj.us/2014/Bills/A3000/2829_S3.PDF. Accessed September 1, 2015.

State of Delaware, The. Delaware Code. Title 16: Health and Safety. Part X: Paramedic and Other Emergency Medical Service Systems. Chapter 98: Paramedic Services. 9802: Definitions. [The Delaware Code Web site]. Available at: http://delcode.delaware.gov/title16/c098/index.shtml. Accessed September 1, 2015.

State of Delaware, The. Delaware Code. Title 18: Insurance Code. Part I: Insurance. Chapter 33: Health Insurance Contracts. 3349: Emergency Care. [The Delaware Code Web site]. Available at: http://delcode.delaware.gov/title18/c033/index.shtml. Accessed September 1, 2015.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

99281, 99282, 99283, 99284, 99285, 99291, 99292

The following procedure code is not covered or eligible for reimbursement, as no direct face-to-face patient care is provided by the physician:

99288


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

Emergency Room:


450 General classification

451 EMTALA* Emergency Medical Screening Services

452 ER Beyond EMTALA* Screening

456 Urgent Care

459 Other Emergency Room

* EMTALA represents the Federal Emergency Medical Treatment and Active Labor Act

Trauma Response:

681 Level I

682 Level II

683 Level III

684 Level IV

689 Other Trauma Response

Professional Fees:

981 Emergency Room



Misc Code

Modifiers:

N/A


Coding and Billing Requirements






Policy History

REVISION MA00.044a:
10/01/2015Revised policy number MA00.044a was issued as a result of annual policy review. The References were updated accordingly. The policy was updated to be consistent with current template wording and format. The adoptable source for this policy is CMS.

All attachments of diagnosis codes have been removed from policy due to the large amount of codes that would need to be maintained. This includes all products.
01/01/2015This is a new policy.




Version Effective Date: 10/01/2015
Version Issued Date: 10/16/2015
Version Reissued Date: N/A