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As previously communicated, reimbursement rates for emergency
room/department (ER) services are inclusive
of services provided to an AmeriHealth Pennsylvania 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
For more information regarding reimbursement for emergency room services,
please review policy #00.10.03i: Criteria
for Reimbursement of Emergency Room Services.
To view this policy, visit our Medical Policy
Portal. Select Accept and Go to Medical Policy Online, and then
select the Commercial tab from the top of the page. 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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