Emergency Department Evaluation and Management Coding for Facility Claims

Date: 05/04/26

Effective 6/1/2026, in order to comply with R.S. 46:460.71(E), Louisiana Healthcare Connections will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the Emergency Department Evaluation and Management (E/M) level for facility claims billed with E/M codes at Level 4 (99284/G0383) and Level 5 (99285/G0384) for services rendered in an emergency department.

Providers will receive a denial for facility claims billed with E/M codes at Level 4 and Level 5 when the EDC Analyzer determines the Calculated Visit Level does not match the emergency department E/M services billed. To prevent claims denials, facilities should comply with CMS coding principles when billing for emergency department services.

If the provider agrees with the claim denial, a corrected claim using the appropriate emergency department E/M level can be submitted for processing.  Please see our Provider Manual corrected claims requirements on page 140.

If the provider disagrees with the claim denial, a Claim Dispute Form (PDF) with supporting documentation requesting a reconsideration of the claim denial can be submitted for processing.

Providers will see claims denied with the following EX, CARC and RARC codes:

• EX R5 - DENY: E/M CODE DENIED.  Rebill with APPROPRIATE LEVEL E/M CODE;
• CARC 16 - Claim/service lacks information or has submission/billing error(s);
• RARC M51 - Missing/incomplete/invalid procedure code(s).

Facility claims excluded from a review by the EDC Analyzer include:

• Patient is admitted to inpatient, observation, or has an outpatient surgery during the course of the same emergency department visit;
• Critical care patients (99291, 99292);
• Patient is less than 2 years old;
• Patients who have expired in the emergency department.

Provider can learn more about the EDC Analyzer (PDF).