Wednesday, January 9, 2013

Emergency CPT - 99283, 99284, 99285, 99281, 99282

Procedure code and Descripiton

99281  (CPT G0380)   Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.

99282 (CPT G0381)   Emergency department visit for the evaluation and management of a patient,
which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.

99283  (CPT G0382)  Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

99284  (CPT G0383)  Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. average fee payment - $110 - $120


Moderate-High Complexity (99284/G0383): The presented problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Head injury instructions, crutch training, bending, lifting, weight-bearing limitations, prescription medication with review of side effects and potential adverse reactions; patient may have questions, but otherwise demonstrates adequate understanding of instructions either verbally or by demonstration. 


99285  (G0384) Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. average fee amount - $170 - $180

99288    Physician direction of emergency medical systems (EMS) emergency care, advanced life support



Billing and Coding Guidelines.

Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

Example #1: A patient is seen in the ED with complaint of a rapid heartbeat.  A 12-lead ECG is performed. In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25
93005 (Twelve lead ECG)


Example #2: A patient is seen in the ED after a fall. Lacerations sustained  from the fall are repaired and radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25
12001-13160 (Repair/Closure of the Laceration)
70010-79900 (Radiological X-ray)


Example #3: A patient is seen in the ED after a fall, complaining of shoulder pain. Radiological x-rays are performed. In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25
70010-79900 (Radiological X-ray)

NOTE: Using example #3 above, if a subsequent ED visit is made on the same date, but no further procedures are performed, appending modifier –25 to that subsequent ED E/M code is NOT appropriate. However, in this instance, since there are two ED E/M visits to the same revenue center (45X), condition code G0 (zero) must be reported in form locator 24 or the corresponding electronic version of the UB92.


Per CPT definition, the codes 99281-99285 are for reporting evaluation and management services in the emergency department. An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day. Based on this definition, codes 99281-99285 will be denied provider liable as incompatible if submitted with any place of service (POS) other than 23. 





If my patient is registered in the emergency department and I am asked to see him/her, may I submit the emergency service?

Answer: 
Yes. Any physician seeing a patient registered in the emergency department (ED) may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the ED. If the patient is admitted by this provider, the initial hospital service (CPT codes 99221-99223) with the AI HCPCS modifier would be submitted instead of the ED visit codes. Please keep in mind the service must be medically necessary and the documentation must meet the level of complexity of the service rendered.

The following guidelines apply to the ED CPT codes 99281 through 99285 billing:

ED service is provided to the patient by both the patient's personal physician and ED physician. If the ED physician, based on the advice of the patient's personal physician who came to the ED to see the patient, sends the patient home, then the ED physician should bill the appropriate level of ED service. The patient's personal physician should also bill the level of ED code that describes the service he or she provided in the ED. If the patient's personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient's personal physician may not bill.

If the ED physician requests that another physician evaluate a given patient, the other physician should bill an ED visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he/she should bill an initial hospital care code and not an ED visit code.


CPT Code 99285 Emergency Department Visit:

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status:

• Comprehensive history

• Comprehensive examination

• Medical decision making of HIGH complexity Comprehensive History:

• Reason for admission

• Problem pertinent review of systems

• Extended history of present illness (HPI) - Includes 4 or more elements of the HPI or the status of at least three chronic
or inactive conditions

• Review of systems directly related to the problem(s) identified in the HPI

• Medically necessary review of ALL body systems’ history

• Medically necessary complete past, family, and social history


HPI – History of Present Illness:

A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present  illness may include:

• Location

• Quality

• Severity

• Timing

• Context

• Modifying factors

• Associated signs/symptoms significantly related  to the presenting problem(s) 


Chief Complaint:

The Chief Complaint is a concise statement from the patient describing:

• The symptom

• Problem

• Condition

• Diagnosis

• Physician recommended return, or other factor that is the reason for the encounter



Review of Systems: An inventory of body systems obtained through a series  if questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purpose of Review of Systems the following systems are recognized:

• Constitutional (i.e., fever, weight loss)

• Eyes

• Ears, Nose, Mouth Throat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary (skin and/or breast)

• Neurologic

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic


Past, Family, and/or Social History (PFSH):  Consists of a review of the following:

• Past history (patient’s past experiences with illnesses, operations, injuries, and treatments

• Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk)

• Social History (an age appropriate review of past and current activities Additional Information:

• Medicare Providers are responsible for assuring that visits are coded accurately; the unique provider number used when a service is billed ensures that the provider has reviewed and authenticated the accuracy of everything on the submitted claim.

• Clearly document your clinical perception of the patient’s condition to assure claims are submitted with the correct level of service.

• Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes UNLESS their presence significantly increases the complexity of the medical decision making.

• Practitioner’s choosing to use time as the determining factor:

- MUST document time in the patient’s medical record

- Documentation MUST support in sufficient detail the nature of the counseling

- Code selection based on total time of the face-to-face encounter (floor time), the medical  record MUST be documented in sufficient detail to justify the code selection



Coding Guidelines


Evaluation and management services including new or established patient office or other outpatient services (99201-99215), emergency department services (99281-99285), nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-99337), home services (99341-99350), and preventive medicine services (99381-99397) on the same date related to the admission to “observation status” should not be reported separately.”


Exceptions to Modifier 59 Override:

The Health Plan has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending modifier 59 to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement (See also our Screening Services with Evaluation & Management Services and our Bundled Services and Supplies reimbursement policies.):

• Duplicate coding

• Services and supplies specified in the Bundled Services and Supplies Policy

• E/M or DME item codes

• National Correct Coding Initiative (NCCI) edit code pairs with a ‘superscript’ of zero, or a modifier allowance indicator of zero.


• In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples:


700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (These code ranges include all applicable radiology interpretation codes, as well as radiology codes with modifier 26) reported with 99221-99233 and 99281-99285*



93010, 93018, 93042, 93303, 93307-93308, 93312-93318, 93320-93321, 93325, 93350-93352, and 0180T reported with 99281-99285


Modifier 25 Guidelines

1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25.

2. Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are:

99201-99215 (Office or Outpatient Services)

99281-99285 (Emergency Department Services)

99291 (Critical Care Services)

99241-99245 (Office or Other Outpatient Consultations)

NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to “physician” are to be disregarded.

Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon.

The pulmonary function tests are reported without an E/M service code. However, an E/M service  code with the modifier –25 appended should be reported to indicate that the afternoon hypertension clinic visit was not related to the pulmonary function testing.

3. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

Example #1: A patient is seen in the ED with complaint of a rapid heartbeat.

A 12-lead ECG is performed.

In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25


93005 (Twelve lead ECG)



045X 99281-99285, 99291 Emergency visit hospital billing UB 04

*Revenue codes have not been identified for these procedures, as they can be performedin a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360), or clinic (0510). Hospitals are to report these HCPCS codes under the revenue center where they were performed. 

EXAMPLE 1

If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, two separate bills may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to OPPS. In this situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit. 

EXAMPLE 2

If a patient was seen in the emergency room (ER) and the same patient received nonpartial hospitalization psychological services on the same day as well as several other days in the month, the provider should report the ER visit on the monthly repetitive claim along with the psychological services, since both services are paid under OPPS.  Days after the date covered services ended, such as noncovered level of care, or emergency services after the emergency has ended in nonparticipating institutions;

• Days for which no Part A payment can be made because the patient was on a leave of absence and was not in the hospital.

• Days for which no Part A payment can be made because a hospital whose provider agreement has terminated, expired, or been cancelled may be paid only for covered inpatient services during the limited period following such termination, expiration, or cancellation. All days after the expiration of the period are noncovered. See Chapter 3 for determining the effective date of the limited period and for billing for Part B services; and

• Days after the time limit when utilization is not chargeable because the beneficiary is at fault. 

FL 19 - Type of Admission/Visit Required on inpatient bills only. This is the code indicating priority of this admission. Code Structure:

1 Emergency - The patient required immediate medical intervention as a result of severe, life threatening or potentially disabling conditions. Generally, the patient was admitted through the emergency room.

2 Urgent- The patient required immediate attention for the care and treatment of a physical or mental disorder. Generally, the patient was admitted to the first available, suitable accommodation.

3 Elective - The patient’s condition permitted adequate time to schedule the availability of a suitable accommodation.  FL 20 - Source of Admission Required For Inpatient Hospital. The provider enters the code indicating the source of this admission or outpatient registration. Code Structure (For Emergency, Elective, or Other Type of Admission):

1 Physician Referral Inpatient: The patient was admitted to this facility upon the recommendation of their personal physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by their personal physician or the patient independently requested outpatient services (self-referral).

2 Clinic Referral Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s clinic physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by this facility’s clinic or other outpatient department physician.

3 HMO Referral Inpatient: The patient was admitted to this facility upon the recommendation of a HMO physician. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a HMO physician.

4 Transfer from a Hospital Inpatient: The patient was admitted to this facility as a transfer from an acute care facility where they were an inpatient Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another acute care facility.

5 Transfer from a SNF Inpatient: The patient was admitted to this facility as a transfer from a SNF where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where they are an inpatient. 

6 Transfer from Another Health Care Facility Inpatient: The patient was admitted to this facility from a health care facility other than an acute care facility or SNF. This includes transfers from nursing homes, long term care facilities and SNF patients that are at a nonskilled level of care. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where they are an inpatient.

7 Emergency Room Inpatient: The patient was admitted to this facility upon the recommendation of this facility’s emergency room physician. Outpatient: The patient received services in this facility’s emergency department.

8 Court/Law

Enforcement Inpatient: The patient was admitted to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative. Outpatient: The patient was referred to this facility upon the direction of a court of law, or upon the request of a law enforcement agency representative for outpatient or referenced diagnostic services. 9 Information Not Available Inpatient: The means by which the patient was admitted to this facility is not known. Outpatient: For Medicare outpatient bills, this is not a valid code. A Transfer from a Critical Access Hospital (CAH) Inpatient: The patient was admitted to this facility as a transfer from a CAH where they were an inpatient. Outpatient: The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient. Code Title Definition

44 Inpatient Admission Changed to Outpatient For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. Effective April 1, 2004

45 Reserved for national assignment

46 Non-Availability Statement on File A nonavailability statement must be issued for each TRICARE claim for nonemergency inpatient care when the TRICARE beneficiary resides within the catchment area (usually a 40-mile radius) of a Uniformed Services Hospital.

47 Reserved for TRICARE  Code Title Definition

59 Non-primary ESRD Facility Code indicates that ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility. 

60 Operating Cost Day Outlier Day Outlier obsolete after FY 1997. (Not reported by providers, not used for a capital day outlier.) PRICER indicates this bill is a length-of-stay outlier. The FI indicates the cost outlier portion paid value code 17. 

AM Non-emergency Medically Necessary Stretcher Transport Required

For ambulance claims. Non-emergency medically necessary stretcher transport required. Effective 10/16/03 AN Preadmission Screening Not Required Person meets the criteria for an exemption from preadmission screening. Effective 1/1/04

G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0. 

Code Title Definition

A4 Covered Self-Administrable Drugs

- Emergency The amount included in covered charges for self-administrable drugs administered to the patient in an emergency situation. (The only covered Medicare charges for an ordinarily noncovered, selfadministered drug are for insulin administered to a patient in a diabetic coma. 

045X Emergency Room

Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care.

Rationale: Permits identification of particular items for payers. Under the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital with an emergency department must provide, upon request and within the capabilities of the hospital, an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual’s eligibility for Medicare (Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985). Subcategory Standard Abbreviations

0 - General Classification EMERG ROOM
1 - EMTALA Emergency Medical screening services ER/EMTALA
2 - ER Beyond EMTALA Screening ER/BEYOND EMTALA
6 - Urgent Care URGENT CARE
9 - Other Emergency Room OTHER EMER ROOM

051X Clinic

Clinic (nonemergency/scheduled outpatient visit) charges for providing diagnostic, preventive, curative, rehabilitative, and education services to ambulatory patients.Rationale: Provides a breakdown of some clinics that hospitals or third party payers may require.

Subcategory Standard Abbreviations

0 - General Classification CLINIC
1 - Chronic Pain Center CHRONIC PAIN CL
2 - Dental Clinic DENTAL CLINIC
3 - Psychiatric Clinic PSYCH CLINIC

Usage Notes:

1. To be used by trauma center/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation.

2. Revenue Category 068X is used for patients for whom a trauma activation occurred. A trauma team activation/response is a “Notification of key hospital personnel in response to triage information from pre-hospital caregivers in advance of the patient’s arrival.”

3. Revenue Category 068X is for reporting trauma activation costs only. It is an activation fee and not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will normally be both a 045X and 068X revenue code reported.

4. Revenue Category 068X is not limited to admitted patients.

5. Revenue Category 068X must be used in conjunction with FL 19 Type of Admission/Visit code 05 (“Trauma Center”), however FL 19 Code 05 can be used alone. 

098X Professional Fees - Extension of 096X & 097X Subcategory Standard Abbreviations

1 - Emergency Room PRO FEE/ER
2 - Outpatient Services PRO FEE/OUTPT
3 - Clinic PRO FEE/CLINIC
4 - Medical Social Services PRO FEE/SOC SVC
5 - EKG PRO FEE/EKG
6 - EEG PRO FEE/EEG
7 - Hospital Visit PRO FEE/HOS VIS
8 - Consultation PRO FEE/CONSULT
9 - Private Duty Nurse FEE/PVT NURSE

• Accommodations - 0100s - 0150s, 0200s, 0210s (days)
• Blood pints - 0380s (pints)
• DME - 0290s (rental months)
• Emergency room - 0450, 0452, and 0459 (HCPCS code definition for visit or procedure)
• Clinic - 0510s and 0520s (HCPCS code definition for visit or procedure)
• Dialysis treatments - 0800s (sessions or days)
• Orthotic/prosthetic devices - 0274 (items)
• Outpatient therapy visits - 0410, 0420, 0430, 0440, 0480, 0900, and 0943 (Units are equal to the number of times the procedure/service being reported was performed.)
• Outpatient clinical diagnostic laboratory tests - 030X-031X (tests)
• Radiology - 032x, 034x, 035x, 040x, 061x, and 0333 (HCPCS code definition of tests or services)
• Oxygen - 0600s (rental months, feet, or pounds)
• Drugs and Biologicals- 0636 (including hemophilia clotting factors) 

If the patient is self-referred (e.g., emergency room or clinic visit), the provider enters SLF000 in the first six positions, and does not enter a name FL19 - Type of Admission

a. One numeric position.
b. Required only if the type of bill is 11X or 41X.

c. Valid codes are:

1 Emergency
2 Urgent
3 Elective
9 Information unavailable 

c. Valid codes are:

1. Physician referral
2. Clinic referral
3. HMO referral
4. Transfer from a hospital
5. Transfer from a SNF
6. Transfer from another health care facility
7. Emergency room
8. Court/Law enforcement
9. Information not available

A. Inpatient - Patient admitted to this facility as an inpatient transfer from a CAH.

Outpatient - Patient referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH where the patient is an inpatient.

B. Patient admitted to this HHA as a transfer from another HHA.


C. Patient readmitted to this HHA within the same home health episode period. 


Indications

Emergency Department services are services provided to a patient in the emergency department or emergency room of a hospital. It is appropriate for the primary physician in the emergency department seeing the patient to use these codes.

Limitations 

If the patient is admitted to the hospital, the admitting physician should code as a hospital admission (99221 - 99223) even if the encounter began in the emergency department.

If the patient is in the ED (ER) for an extended time. i.e., several hours, there should be only one charge for a primary physician for that visit (except as indicated in "Coding Guidelines"). The length of time per se that the patient is in the ED (ER) does not determine the level of service provided. A prolonged visit does not warrant more than one E & M code being submitted for the visit. Additional E & M codes should not be submitted if the patient is seen by more than one primary physician in the emergency department because of a "shift" change.

Prolonged service codes may not be used with emergency department E & M codes.

Emergency Services


Emergency Care means health care services provided in a Hospital emergency facility (emergency room), freestanding emergency medical care facility, or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that the person's condition, sickness, or injury is of such a nature that failure to get immediate care could result in:

1. placing the patient's health in serious jeopardy;
2. serious impairment of bodily functions;
3. serious dysfunction of any bodily organ or part;
4. serious disfigurement; or

5. in the case of a pregnant woman, serious jeopardy to the health of the fetus.


Reimbursement for emergency inpatient hospital services is permitted only for those periods during which the patient's state of injury or disease is such that a health or life-endangering emergency existed and continued to exist, requiring immediate care that could be provided only in a hospital. The allegation that an emergency existed must be substantiated by sufficient medical information from the physician or hospital. If the physician's statement does not provide it, or is not supplemented by adequate clinical corroboration of this allegation, it does not constitute sufficient evidence.

Death of the patient does not necessarily establish the existence of a medical emergency, since in some chronic, terminal illnesses, time is available to plan admission to a participating hospital. The lack of adequate care at home or lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission, without an immediate threat to the life and health of the patient. Since the existence of medical necessity for emergency services is based upon the physician's assessment of the patient prior to admission, serious medical conditions developing after a non-emergency admission are not "emergencies" under the emergency services provisions of the Act.

The emergency ceases when it becomes safe, from a medical standpoint, to move the individual to a participating hospital, another institution, or to discharge the individual.

B. Criteria

Since the decision that a medical emergency existed can be a matter of subjective medical judgment involving the entire gamut of disease and accident situations, it is impossible to provide arbitrary guidelines.

1. Diagnosis is Considered "Usually an Emergency"

An emergency condition is an unanticipated deterioration of a beneficiary's health which requires the immediate provision of inpatient hospital services because the patient's chances of survival, or regaining prior health status, depends upon the speed with which medical or surgical procedures are, or can be, applied. While many diagnoses (e.g., myocardial infarction, acute appendicitis) are normally considered emergencies, the hospital must check medical documentation for internal consistencies (e.g., signs and symptoms upon admission, notations concerning changes in a preexisting condition, results of diagnostic tests).

EXAMPLE: If the diagnosis is given as "coronary," the physician's statement is "coronary," without further explanatory remarks, and the statement of services rendered gives no indication that an electrocardiogram was taken, or that the patient required intensive care, etc., further information is required. On the other hand, if the diagnosis is one that ordinarily indicates a medical and/or surgical emergency, and the treatment, diagnostic procedures, and period of hospitalization are consistent with the diagnosis, further documentation may be unnecessary. An example is: admitting diagnosis - appendicitis; discharge diagnosis - appendicitis; surgical procedures - appendectomy; period of inpatient stay - 7 days.

2. Patient Dies During Hospitalization

If an emergency existed at the time of admission and the patient subsequently expires, the claim is allowed for emergency services if the period of coverage is reasonable. However, death of the patient is not prima facie evidence that an emergency existed; e.g., death can occur as a result of elective surgery or in the case of a chronically ill patient who has a long terminal hospitalization. Such claims are denied.

3. Patient's Physician Does Not Have Staff Privileges at a Participating Hospital

The fact that the beneficiary's attending physician does not have staff privileges at a participating hospital has no bearing  on the emergency services determination. If the lack of staff privileges in an accessible participating hospital is the governing factor in the decision to admit the beneficiary to an "emergency hospital," the claim is denied irrespective of the seriousness of the medical situation.

4. Beneficiary Chooses to be Admitted to a Nonparticipating Hospital

The claim is denied if the beneficiary chooses to be admitted to a non-participating hospital as a personal preference (e.g., participating hospital is on the other side of town) when a bed for the required service is available in an accessible, participating hospital.

5. Beneficiary Cannot be Cared for Adequately at Home

The patient who cannot be cared for adequately at home does not necessarily require emergency services. The claim is denied in the absence of an injury, the appearance of a disease or disorder, or an acute change in a pre-existing disease state which poses an immediate threat to the life or health of the individual and which necessitates the use of the most accessible hospital equipped to furnish emergency services.

6. Lack of Suitable Transportation to a Participating Hospital

Lack of transportation to a participating hospital does not, in and of itself, constitute a reason for emergency services. The availability of suitable transportation can be considered only when the beneficiary's medical condition contraindicates taking the time to arrange transportation to a participating hospital. The claim is denied if there is no immediate threat to the life or health of the individual, and time could have been taken to arrange transportation to a participating hospital.

7. "Emergency Condition" Develops Subsequent to a Non-emergency Admission to a Nonparticipating Hospital

Program payment cannot be made for emergency services furnished by a nonparticipating hospital when the emergency condition arises after a non-emergency admission. An example: treatment of postoperative complications following an elective surgical procedure or treatment of a myocardial infarction that occurred during a hospitalization for an elective surgical procedure. The existence of medical necessity for emergency services is based upon the physician's initial assessment of the apparent condition of the patient at the time of the patient's arrival at the hospital, i.e., prior to admission.


8. Additional "Emergency Condition" Develops Subsequent to an Emergency Admission to a Nonparticipating Hospital


If the patient enters a nonparticipating hospital under an emergency situation and subsequently has other injuries, diseases or disorders, or acute changes in preexisting disease conditions, related or unrelated to the condition for which the patient entered, which pose an immediate threat to life or health, emergency services coverage continues. Emergency services coverage ends when it becomes safe from a medical standpoint to move the patient to an available bed in a participating institution or to discharge the patient, whichever occurs first.

Emergency Medical Condition

An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If you didn’t get immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would have serious damage to any part or organ of your body.


Emergency Medical Transportation

Ambulance services for an emergency medical condition. Types of emergency medical transportation may include transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or may pay less for certain types.


Emergency Room Care / Emergency Services

Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions.

Urgent Care


Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

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