Emergency Room Services - Facility Coding Guidelines

For Emergency Room services, the facility provider should bill on a UB-04 or the electronic equivalent.

Emergency Room Payment

HMSA’s payment for Emergency Room services is based on an all-inclusive rate that includes the emergency room staff, the use of the emergency room, associated medical or surgical supplies and pharmacy items.

There are common services that are performed in conjunction with an Emergency Room visit and are not included in the Emergency Room Payment such as:

• Diagnostic Services such as laboratory tests and x-rays
  • These services are paid separately based on the accompanying CPT or HCPCS codes. The eligible charges for diagnostic services are based on HMSA MAC fee schedule pricing.
• Observation/Treatment/Labor Room
  • Use of an Observation, Treatment or Labor Room is paid separately. Refer to Observation Services’ Policy III. B.
• Take-Home Drugs, Take-Home Supplies or Patience Convenience Items
  • These services are not a covered benefit and are not payable.

Emergency Room with Ambulatory Service Center (ASC) or Inpatient Admission

ASC Admission

If a member is admitted into an Ambulatory Surgical Center (ASC) directly from the Emergency Room, the Emergency Room Service will be considered part of the ASC PRG reimbursement and will not be paid separately.

Inpatient Admission

If a member is admitted into a hospital for inpatient services directly from the Emergency Room, the Emergency Room Service will be considered part of the Inpatient DRG reimbursement and will not be paid separately.

Emergency Room Benefit

HMSA covers the use of an Emergency Room only to stabilize a medical condition which is accompanied by acute symptoms of sufficient severity (including serve pain) that a prudent layperson could reasonably expect the absence of immediate medical attention to result in:

• Serious risk to the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child).
• Serious impairment to bodily functions.
• Serious dysfunction of nay bodily organ or part.

Examples an Emergency Include:

• Chest pain or other heart attack signs
• Poisoning
• Loss of consciousness
• Convulsions or seizures
• Broken back or neck
• Heavy bleeding
• Sudden weakness on one side
• Severe pain
• Breathing problems
• Drug overdose
• Severe allergic reaction
• Severe burns
• Broken Bones

Example of Non-Emergency Include:

• Colds
• Flu
• Earaches
• Sore throat
• Convenience
• During normal physician hours for medical conditions that can be treated by a physician’s office

Coding

Using the correct combination of codes is the key to minimizing delays in claims processing. Please ensure that revenue codes and procedure codes reflect the diagnoses and services rendered. Third-digit subcategories for the revenue code are included in the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

Commonly Billed Services

The matrix below depicts commonly billed services and acceptable codes that correspond to HMSA's claims processing requirements for Emergency Room Services. The matrix represents a range of possible combinations and should not be viewed as comprehensive.

Emergency Room and Ancillary Services

Drugs Requiring Specific Identification

Notes: Drugs requiring specific identification must be billed as separate line items on the facility claim. In general, these items are included in the all-inclusive rate and are not reimbursed separately. However, exceptions for high costing drugs may be allowed upon written request.

Please send a written request with your supporting documentation to the address listed below.

HMSA - Provider Operations
ATTN: Research and Correspondence
P.O. Box 860
Honolulu, HI  96808-0860

Billing Tips

Frequency of Billing

File a separate claim for each emergency room visit, even if the member revisits the same emergency room on the same day.

Note: When a member visits the emergency room more than once in a 24-hour period, include an explanation in the remarks section (form locator 80) of the UB-04. Alternately, a copy of the emergency room report may be attached to the second (and subsequent) claim.

Service Units

Identify each emergency room visit by entering "1" in form locator 46. This unit value should never be greater than one when billing revenue code 450.

Physician Services

Emergency physician services should not be billed with emergency room services on the UB-04. Physician services (when billed by hospitals) should be billed on the CMS 1500 claim form using the HMSA-assigned provider number for professional services.

Span Dates

Bill for the date the member was admitted into the emergency room.

UB-04 Highlights: Sample Claim

See Emergency Room - UB-04 Highlights [PDF] for an illustration of the claim explained below.
Note: It may be helpful to print the sample claim, then return to this page.

Explanation of Sample Claim

Revision History