QUEST Integration – Emergency Room Services

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Services provided on the same day as a covered emergency room service that are covered and separately billable include but are not limited to:

• Emergency room facility fee
• Diagnostic testing (laboratory testing, radiology, other imaging procedures)
• Therapeutic services and treatments such as inhalation treatment, intravenous infusion, injections of antibiotics, etc
• Medical supplies such as casting material, splints, intravenous administration sets.
• Certain durable medical equipment for use by the specific patient such as crutches.

Exclusions and Limitations

• Emergency room services that result in an inpatient admission to the acute care hospital are considered part of the inpatient hospital stay.
• Physician services
• Ambulance services
• Standard emergency room supplies and equipment such as blood pressure monitoring devices, sheets, under_pads, suction machines, sutures, scissors, oximeters, bed pans, thermometers, tongue blades, etc.
• Supplies that are an integral part of the procedures. Examples are clean catch kits when urinalysis and/or cultures are done, electrodes when ECGs are done, blood specimen containers when blood chemistries are drawn. Usage of updraft, nebulizer and oxygen are not billable as supplies.

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 and visit times. On paper claim submissions, use the remarks section (form locator 80) of the UB-04 to indicate that the member was seen twice on the same day and include the time for the billed visit. On electronic claims, use the notes field (electronic loop 2300) to provide the information. Alternately, a copy of the emergency room report may be attached to the second (and subsequent) claim.

Revision History