Emergency Department Codes Billed in Nonemergency Department Sites of Service

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for patients receiving care in Nonemergency Department Sites of Service.

For your personalized six-month Emergency Department Services Procedure Codes Billed in Nonemergency Department Sites of Service results Logon to eServices. 

This eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Becoming proactive in addressing potential billing issues and performing internal audits will help ensure you are in compliance with Medicare guidelines.

Overview 

Under the Outpatient Prospective Payment System (OPPS), hospitals report Type A emergency department visits using Current Procedural Terminology® (CPT®) codes 99281–99285. Hospitals report Type B emergency department visits using Healthcare Common Procedure Coding System (HCPCS) codes G0380–G0384. Hospitals report hospital outpatient clinic visits using CPT® codes 99201–99215 and 99241–99245.

A Type A provider-based emergency department must meet at least one of the following requirements:

• It is licensed by the state in which it is located under applicable state law as an emergency room or emergency department and be open 24 hours a day, seven days a week; or
• It is held out to the public (by name, posted signs, advertising or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment and be open 24 hours a day, seven days a week

A Type B provider-based emergency department must meet at least one of the following requirements:

• It is licensed by the state in which it is located under applicable State law as an emergency room or emergency department, and open less than 24 hours a day, seven days a week; or
• It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment, and open less than 24 hours a day, seven days a week; or
• During the calendar year immediately preceding the calendar year in which a determination under 42 Code of Federal Regulations (CFR) 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment, regardless of its hours of operation.

Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. The Centers for Medicare & Medicaid Services (CMS) outlines its minimal documentation requirement in the Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 220.3 (PDF).

CMS works to eliminate improper payments in the Medicare Program and protect the Medicare Trust Fund, as well as beneficiaries from medically unnecessary services or supplies and their associated costs. CMS calculates a national Medicare Fee-For-Service (FFS) improper payment rate and improper payment rates by claim type and publishes the review results annually.

Methods

The metrics reviewed in this eCBR are the proportion of billing for claims rejected for improper use of Emergency Department Services Procedure Codes Billed in Nonemergency Department Sites of Service billed claims for comparisons done to peers within the state and jurisdiction. This report is an analysis of Medicare Part A claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing at each level compared to your peers in Jurisdictions J and M.

Example of eCBR

Resources

• Audit of Medicare Payments for Emergency Department Services Provided in Nonemergency Department Sites of Service
• OPPS Visit Codes Frequently Asked Questions (PDF)
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 8 (PDF)
• Medicare Claims Processing Manual, Publication 100-04, Chapter 6 (PDF)
• Medicare Program Integrity Manual, Publication 100-08, Chapter 3 (PDF)