TMPPM 2009 > Texas Medicaid Services > Hospital (Medical/Surgical Acute Care Facility) > Outpatient

   
 

25.3.3.7 Emergency Department Services

An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to clients who present for immediate medical attention. The facility must be available 24 hours a day, 7 days a week. Hospital-based emergency departments are reimbursed for services based on a reasonable cost, based on the hospital's most recent tentative Medicaid cost report settlement. The reasonable cost is reduced by a percentage determined by the state.

Emergency department room charges may be billed using the following revenue codes:

Revenue Code
Description

450
or
451
or

456
or
459

Emergency room
or
Emergency room-EMTALA emergency medical screening
or
Emergency room, urgent care
or
Emergency room-other

761

Treatment room

762

Observation room

Emergency department ancillary services include laboratory services, radiology services, respiratory therapy services, and diagnostic studies, such as ECGs, CT scans, and supplies. Ancillary services should be billed on a UB-04 CMS-1450 claim form using the appropriate procedure codes such as the Current Procedural Terminology (CPT) code or the HCPCS code indicating the procedures or services performed.

According to EMTALA, if any individual presents at the hospital's emergency department requesting an examination or treatment, the hospital must provide an appropriate medical screening examination and stabilization services within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists.

EMTALA medical screening code (451) may be considered for reimbursement when billed as a stand-alone service and provided by a qualified medical professional as designated by the facility. Ancillary, professional, or facility services will not be considered for separate reimbursement. Services beyond screening (451) can be billed with the appropriate corresponding emergency services code (450).

Medicaid claims administrators and Medicaid Managed Care Organizations (MCOs) are prohibited from requiring prior authorization or primary care provider notification for emergency services including those that are needed to evaluate or stabilize an emergency medical condition or emergency behavioral health condition.

Texas Medicaid provides that certain undocumented aliens and legalized aliens who require treatment of an emergency medical condition or emergency behavioral health condition are eligible to receive that treatment. After the emergency condition requiring care is stabilized and no longer an emergency, the coverage ends. If the alien continues to receive ongoing treatment after the emergency ceases, the ongoing treatment is not a benefit.

Texas Medicaid provides for medical services for eligible clients while out-of-state. The attending physician or other provider must document that the client was treated for an emergency condition. Out-of-state emergency services are also a benefit when the client's health would be in danger if he or she were required to travel back to Texas.

Emergency department services are subject to retrospective review.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2008 American Medical Association. All rights reserved.
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