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As previously communicated, reimbursement rates for emergency
room/department (ER) services are inclusive of services provided to an
Independence member during the visit. This reimbursement includes the
professional components of laboratory and radiology for all managed care
Benefit Programs. Therefore, there is no separate or additional reimbursement
for these services.
ER services when billed with surgical services
If an ER visit includes surgery performed in a fully equipped and staffed
operating room, the facility will receive fee schedule reimbursement for the ER
visit and the surgery. In this circumstance, the surgery should be billed using
an appropriate surgery revenue code with the applicable
HCPCS/CPT® code.
When surgical services are performed in the ER and not a fully
equipped operating room, the surgical services are included in the
reimbursement for the ER visit. In this circumstance, the surgery should be
billed using an appropriate ER revenue code with the applicable HCPCS/CPT
code.
Services billed together | Services reimbursed* | Revenue
code requirements |
Surgical services performed in the operating room and emergency
services performed in the ER | Both ER services and surgical services are
reimbursed | Surgical services reported with 36x, 481, 49x, or 790; ER
services reported with 45x |
Surgical services and emergency services performed in the ER | ER
services are reimbursed | Surgical services reported with 45x; ER
services reported with 45x |
*Fee schedule reimbursement
for these services includes all services provided during the visit, including
the professional components of laboratory and radiology.
Learn more
Additional information regarding observation services in the ER can be found
in the Billing & Reimbursement for Hospital Services section of the Hospital
Manual for Participating Hospitals, Ancillary Facilities, and Ancillary
Providers.
For more information regarding reimbursement for emergency room services,
please review the following policies:
- Commercial: #00.10.03i: Criteria for Reimbursement of Emergency Room
Services
- Medicare Advantage: #MA00.044a: Criteria for Reimbursement of
Emergency Room Services
To view these policies, visit our
Medical Policy Portal. Select
Accept and Go to Medical
Policy Online, and then select the
Commercial or
Medicare
Advantage tab from the top of the page, depending on the version of the
policy you?d like to view. Then type the policy name or number in the Search
field.
If you have any questions, please contact your Network Coordinator.
CPT copyright 2014 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association.
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