Provider updates

As part of our continued efforts to reinforce accurate coding practices, CareOregon is revising the current emergency department (ED) outpatient facility evaluation and management (E/M) coding reimbursement policy and procedure. This change affects all facilities that bill for ED claims and applies to claims received on or after April 1, 2025 by the following plans:

• Health Share of Oregon
• Jackson Care Connect
• Columbia Pacific CCO
• CareOregon Advantage

These policies focus on outpatient facility ED claims that are submitted with level 3 (99283, G0382), level 4 (99284, G0383), or level 5 (99285, G0384) E/M codes. They were developed using our national experience to address inconsistencies in coding accuracy and were based on the E/M coding principles created by the Centers for Medicare and Medicaid Services (CMS) that require hospital ED facility E/M coding guidelines to follow the intent of CPT code descriptions and reasonably relate to hospital resource use. 

These policies will apply to all facilities, including freestanding facilities, that submit ED claims with level 3, 4, or 5 E/M codes for members of the affected plans, regardless of whether they’re under contract to participate in our network.

As part of the implementation of these policies and procedures, we’ll begin using the Optum Emergency Department Claim (EDC) Analyzer tool, which determines appropriate E/M coding levels based on data from the patient’s claim. This includes the following: 

• Patient’s presenting problem
• Diagnostic services performed during the visit
• Any patient complicating conditions

To learn more about the EDC Analyzer tool, please visit EDCAnalyzer.com

Facilities submitting claims for ED E/M codes may experience adjustments to level 1, 2, 3, 4, or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their contracts with CareOregon. Facilities will have the opportunity to submit reconsideration or appeal requests if they believe a higher-level E/M code is justified, in accordance with the terms of their contract.

Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

• Claims for patients who were admitted from the emergency department or transferred to another health care setting (Skilled Nursing Facility, Long Term Care Hospital, etc.)
• Claims for patients who received critical care services (99291, 99292)
• Claims for patients who are under 2 years old
• Claims with certain diagnosis codes that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
• Claims for patients who expired in the ED

Ultimately, the mutual goal of facility coding is to accurately capture ED resource utilization and align that with the E/M CPT code description for a patient visit per CMS guidance.

If you need further information, please contact CareOregon Customer Service at 503-416-4100 or toll free, 800-224-4840. You may also contact us via email: paymentintegrity@careoregon.org.

Thank you,
The Payment Integrity Department

For more information, read our Emergency Department Outpatient Facility Evaluation and Management Coding Policies.