ED Coding and Reimbursement Alert

Question: Our ED heard at a conference last weekend that our Blue Cross Blue Shield payer may stop paying for ED visits if the patient isn’t actually experiencing an emergency. But we can’t find anything online about it. Is this accurate?

Mississippi Subscriber

Answer: Unfortunately, you heard correctly. Blue Cross Blue Shield of Mississippi announced on December 18 that, effective in 2019, it would deny ED claims for conditions that it later believes did not “align with the severity of the diagnosis code submitted on the ER claim.” The policy requires patients to personally determine whether their diagnoses are true emergencies, which can be challenging when patients have symptoms that could be of serious, emergent conditions or could be something more minor.

This mirrors a policy already in place with Anthem, which has a similar program in select states. Essentially, these payers are counting on patients to know which symptoms are life-threatening, which many people who aren’t professionals in the health care field are unable to do on their own. Many professional associations are fighting this new rule, but as of now, it appears to be in place. Keep an eye on ED Coding and Billing Alert to stay on top of this issue and find out whether it changes in the near future.