Notification



Notification Issue Date:



Medicare Advantage Policy

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

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 diagnostic criteria to determine the appropriate level of reimbursement for these services.

In accordance with the facility and/or professional provider contracts, the following reimbursement methodologies may be applied to facility claims and claims submitted by professional providers who specialize in emergency medicine:
  • Eligible emergent services may be reimbursed at an emergency level.
  • Eligible services that are not considered emergent may be reimbursed at a triage level (i.e., a reduced rate).

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.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage determination for emergency room services. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, emergency room service is covered under the medical benefits of the Company's Medicare Advantage products.

Description

EMERGENCY LEVEL

Reimbursement eligibility for services rendered in an emergency room (ER)/emergency department (ED) setting to participating professional providers and/or to participating facilities is based on diagnostic criteria, the definition of emergency, and all applicable facility provider and/or professional provider 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

TRIAGE LEVEL

When the individual's condition does not meet diagnostic criteria 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 January 28, 2020.

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 January 28, 2020..

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 January 28, 2020..

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 January 28, 2020.

Company Provider Manuals

Evidence of Coverage

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 January 28, 2020.

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 January 28, 2020.


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


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)

0450 Emergency Room - General


0451 Emergency Room - EMTALA Emergency Medical Screening Services

0452 Emergency Room - ER Beyond EMTALA

0456 Emergency Room - Urgent Care

0459 Emergency Room - Other Emergency Room

0681 Trauma Response - Level I

0682 Trauma Response - Level II

0683 Trauma Response - Level III

0684 Trauma Response - Level IV

0689 Trauma Response - Other Trauma Response

0981 Professional Fees - Emergency Room


Coding and Billing Requirements






Policy History

REVISION MA00.044b:
03/23/2020Effective 03/23/2020 policy number ma00.044b was issued as a result of annual policy update. The Adoptable source for this policy is CMS

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: 03/23/2020
Version Issued Date: 03/23/2020
Version Reissued Date: N/A