Introducing the Emergency Department (ED) Coding Program
Emergency department (ED) visit costs are rising which is having direct impact on healthcare spending. Billing for higher-level Evaluation and Management (E&M) codes (Levels 4–5) is increasing but overall patient severity has remained stable.
This trend suggests changes in coding practices, not a meaningful shift in the sickness level of patients (patient acuity). It also reflects the ongoing evolution of medical billing and documentation practices.
Trends like these make it harder for health plans to control growing emergency care costs. Using data-driven, payment integrity strategies helps identify inconsistencies, control costs, and ensure emergency services are reimbursed appropriately.
The ED Facility Coding program addresses these changes by using clinical logic and a stepwise framework to ensure that high-level E&M codes accurately reflect the complexity and emergency department resources used.
The program will launch for group business beginning with dates of service July 3, 2026, and will only apply to Washington in- and out-of-network providers.
Why it matters
There’s no single national formula for assigning facility E&M levels. Instead, hospitals are expected to use internal guidelines that connect coding to actual resources used, such as diagnostics, staff involvement, and patient complexity.
When E&M codes don’t align with the clinical profile of a visit, it can lead to inconsistent billing and unnecessary rework.
What the program does
The ED Facility Coding program is a prepay review of emergency department facility claims. It focuses on higher‑level E&M codes (Level 4 or 5) and evaluates whether those codes are supported.
How it works
- Checks whether billed levels are supported by documented care and resource use
- Uses a consistent, clinically based review approach
- Applies transparent rules across all claims
- Reduces unnecessary variation in coding
How E&M levels are evaluated
Each E&M level reflects the level of resources used during a visit—from basic to complex care.
The program uses a structured five-step review:
- Focus on higher-level claims (excluding critical care, observation services, inpatient admissions, and specific diagnosis categories)
- Check for emergent diagnoses
- Review services provided (tests, procedures, medications)
- Assess complicating conditions
- Confirm the appropriate visit level
Each decision is based on documented care, clinical evidence, and established guidelines. If program assigns a lower level, Premera Blue Cross HMO (PBC HMO) will replace the billed line with a new line and pay at that lower level. Please note this does not apply to contracts that reimburse based on a percent of billed charges; Those claims will be denied and we will ask the facility to resubmit using a lower E&M level.
What doesn’t change
- Access to emergency care
- Coverage for medically necessary emergency services
- Provider responsibility to deliver care based on patient needs
Member experience
Members won’t be negatively affected by this program. In some cases, members may pay less if a claim is adjusted. Any changes are due to coding corrections—not benefit changes. If a claim needs to be corrected, providers are responsible for resubmitting the claim. For out-of-network emergency care, the Federal No Suprises Act protects members from balance billing in most cases.
Please contact your PBC HMO Account Manager with questions.