REIMBURSEMENT POLICY
Medical Emergency
Active
______________________________________________________________________
Policy Number:
Evaluation and Management – 008.002 – Medical Emergency
Policy Title:
Medical Emergency
Section:
Evaluation and Management
Effective Date:
August 16, 2016
Last Reviewed:
January 18, 2017
______________________________________________________________________
Description
This policy addresses coverage and reimbursement for outpatient medical emergency services
and extended or after-hour clinics.
Definitions
Emergency department services (codes 99281-99285) are submitted by the physician or
qualified health care professional assigned to the emergency room.
Hospital-based emergency room care should be billed on the 837I only with the revenue code
0450.
Clinic-based urgent care services may be billed under the place of service (POS) 20 billed on a
professional claim (837P).
Hospital-based emergency room urgent care should be billed on the institutional (837I) only
with the revenue code 0456.
Codes S9083 (global fee urgent care centers) and S9088 (services provided in an urgent care
center) represent where the service was rendered, not the service itself.
Policy Statement
Some subscribers have full coverage for an outpatient medical emergency, which we generally
define as the sudden and unexpected onset of a condition requiring immediate medical
attention. To receive full benefits, the subscriber must seek care within specified time limits,
usually within 24 to 72 hours of the onset of acute symptoms.
Accidental injury may not be included in the medical emergency benefits. Many coverage plans
have separate first-aid or accident benefits.
Criteria for Medical Emergencies
Use the guidelines below to determine if you should submit a claim as a medical
emergency. Medical emergency charges should be submitted with the date and time the
emergency occurred. If the emergency is related to pregnancy, also indicate that the charges
were for emergency services.
 Were the symptoms sudden, severe and life threatening?
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Medical Emergency



Did the condition require immediate medical (not surgical) attention?
Did the patient see a doctor no later than 72 hours after the problem began?
Did the time or date of the visit indicate it was an emergency?
The following situations generally would not indicate a medical emergency:
 scheduled surgeries or diagnostic procedures such as colon or IVP X-rays
 follow-up visits for further injections, such as antibiotics
 suture removal
 urgent but non-life-threatening situations seen during regular office hours
 scheduled medical or routine/preventive visits
Emergency Department Services
Assignment is defined as a formal relationship between the physician or qualified health care
professional and the hospital whereby the physician or qualified health care professional is
solely responsible for seeing patients in the emergency room during a specified time period.
Physicians or qualified health care professionals who specialize in emergency medicine and
use the emergency department as their place of business are generally considered assigned to
the emergency room.
Other physicians or qualified health care professionals who have arrangements with the
hospital to be ‘‘on call’’ to see patients in the emergency department during specific hours may
also be considered assigned to the emergency department while seeing patients there. In this
case, the physician’s or qualified health care professional’s primary responsibility is to the
emergency department and the arrangement is between the physician or qualified health care
professional and the hospital, as opposed to an agreement between physicians or qualified
health care professionals to cover one another’s patients over the weekend, etc.
Any physician or qualified health care professional seeing a patient in the emergency
department to which he/she is not assigned must submit level-of-service office calls according
to CPT guidelines.
Emergency department visit evaluation and management codes are restricted to the
emergency place of service (23) for professional claims (837P), in accordance with CPT coding
rules. Codes 99281-99285 will be denied provider liable as incompatible if submitted with any
place of service (POS) other than 23.
Hospital-based emergency room care should be billed on the 837I only with the revenue code
0450.
Extended/After-hours Clinics
Blue Cross and Blue Shield of Minnesota (Blue Cross) does not consider an extended/afterhours clinic to be an 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.
Clinic-based urgent care services may be billed under the place of service (POS) 20. The POS
code 20 will apply office benefits to the services if submitted. DO NOT bill a corresponding
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Medical Emergency
facility claim with the revenue code 0456 if already billing for urgent care on the professional
claim (837P). This would be considered duplicate billing. Hospital-based emergency room
urgent care should be billed on the 837I only with the revenue code 0456.
Codes S9083 (global fee urgent care centers) and S9088 (services provided in an urgent care
center) represent where the service was rendered, not the service itself. Thus, they are not
separately covered and will be denied as part of the primary service (such as an E/M).
Documentation Submission
Documentation/ must identify and describe the procedures performed. If a denial is appealed,
this documentation must be submitted with the appeal.
Coverage
Eligible services will be subject to the subscriber benefits, Blue Cross fee schedule amount and
any coding edits.
The following applies to all claim submissions.
All coding and reimbursement is subject to all terms of the Provider Service Agreement and subject to
changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal
HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD), only codes valid for the date of
service may be submitted or accepted. Reimbursement for all Health Services is subject to current Blue
Cross Medical Policy criteria, policies found in Provider Policy and Procedure Manual sections,
Reimbursement Policies and all other provisions of the Provider Service Agreement (Agreement).
In the event that any new codes are developed during the course of Provider's Agreement, such new
codes will be reimbursed according to the standard or applicable Blue Cross fee schedule until such time
as a new agreement is reached and supersedes the Provider's current Agreement.
All payment for codes based on Relative Value Units (RVU) will include a site of service differential and
will be calculated, if appropriate, using the appropriate facility or non-facility components, based on the
site of service identified, as submitted by Provider.
Coding
The following codes are included below for informational purposes only, and are subject to
change without notice. Inclusion or exclusion of a code does not constitute or imply member
coverage or provider reimbursement.
CPT / HCPCS Modifier:
N/A
ICD-Diagnosis:
N/A
ICD-Procedures:
N/A
HCPCS:
99281-99285, S9083, S9088
Revenue Codes:
0450, 0456
Deleted Codes:
N/A
Policy History
Initial Committee Approval Date: August 16, 2016
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Medical Emergency
Code Update:
Policy Review Date:
Cross Reference:
N/A
January 18, 2016 – originally published as RP General
Coding – 046.001 – Medical Emergency
RP - General Coding - 011.001 – Urgent Care / After
Hours Care / Extended Hours
2017 Current Procedural Terminology (CPT®) is copyright 2016 American Medical Association. All Rights
Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA
assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to
government use.
Copyright 2017 Blue Cross Blue Shield of Minnesota.
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