Description : Emergency Services.

Required for Claims : Hospital emergency room services spanning multiple service dates.

Type of Bill: 13X, 85X

Coding Guidelines : The –ET modifier should be applied to line item dates of service on their outpatient bill types 13X and 85X that are different from the date of service for revenue code
0450 (Emergency Room).

General Guidelines :

Emergency room (ER) services performed in a hospital are excluded from SNF CB for beneficiaries that are in skilled Part A SNF stays. Hospitals report ER services under the 045X revenue code with a line item date of service (LIDOS) indicating the date the patient entered the ER. Services related to the ER encounter are also excluded from the SNF CB provision. Current CWF SNF CB edits have bypasses to allow ER related services with LIDOS that match the reported LIDOS on the 045X revenue code to bypass SNF CB edits.

Problems arise where services related to the ER encounter span more than one service date. Services related to the ER encounter performed on subsequent service dates are currently being rejected by the CWF because the LIDOS for these services does not match the LIDOS reported under 045x ER revenue code. In order to bypass services related to the ER encounter which are performed on subsequent service dates, hospitals must identify those services by appending a modifier ET (Emergency Services) to those line items. The CWF SNF CB edits shall be updated
to bypass those services related to the ER encounter performed on subsequent dates based on the ET modifier.

Example: Patient comes to the Emergency Room late on April 14th. The patient is not released from the emergency room until April 15th.

BILLING: Services with dates of service from 4/15 must have the –ET modifier applied.

Emergency Services

Authorizations are not required for medically necessary emergency services. Emergency services are defined in your BCBSTX Provider Contract, by state and local law, and in the Member Handbook.

Related professional services offered by physicians during an emergency room visit are reimbursed according to your BCBSTX Provider contract.

For professional emergency services billing, indicate the injury date in Box 14 on the CMS-1500 claim form if applicable.

All Members should be referred back to the Primary Care Provider (PCP) of record for follow-up care. Unless clinically required, follow-up care should never occur in the emergency department of a hospital.


Emergency Service Claims

An emergency is defined as any condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that a layperson possessing an average knowledge of health and medicine could reasonably expect that in the absence of immediate medical care could result in:

Placing the patient’s health or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopard  Causing serious impairment to bodily functions, and Causing serious dysfunction to any bodily organ or part.

Covered services include: hospital-based emergency department services (room and ancillary) needed to evaluate or stabilize an emergency medical condition and/or emergency behavioral health condition, as well as services by emergency professional/physicians.

Hospitals and physicians rendering services in the emergency department will be reimbursed for emergency services at 100% of the applicable rate when services are billed with 99284 and 99285. Hospital and physician reimbursement will be reduced by 40% for services billed with 99281, 99282 and 99283.

This includes a medical screening to evaluate care levels and stabilization services needed to admit or release patient. Physicians must use Medicaid allowable codes to identify emergency services.