Emergency Medicine Prior Authorization and Denial Guide
E&M level selection, facility vs. professional claim split, No Surprises Act compliance, observation vs. inpatient status, and critical care billing, grounded in CMS Chapter 12 of the Medicare Claims Processing Manual, ACEP coding guidelines, the Two-Midnight Rule, and PHSA §2719A (No Surprises Act).
No Surprises Act protections: the NSA (effective January 1, 2022) prohibits out-of-network emergency providers from balance billing patients for emergency services, and requires that OON emergency services be covered at in-network cost-sharing levels. Insurers must pay either the QPA (Qualifying Payment Amount — the median in-network rate for the service and geographic area) or a higher amount determined through the Independent Dispute Resolution process. Providers who believe the QPA undervalues their services can initiate IDR through a certified IDR entity. Emergency medicine providers face CO-96 denials when insurers apply incorrect QPA calculations or misclassify services.
E&M level documentation for ED visits (CPT 99281–99285) follows the 2021 AMA guidelines based on MDM or total physician time. High-acuity ED visits (99284, 99285) require documentation of high MDM — which in the ED context includes high-risk decision making, prescription drug management, or ordering/reviewing tests that require intensive interpretation. Observation status (CPT 99218–99220 or G0378/G0379) vs. inpatient admission follows the Two-Midnight Rule for Medicare: an inpatient admission is appropriate when the admitting physician expects the patient to require hospital care spanning two midnights based on the clinical picture at the time of admission.