Review of professional claims with emergency department level 5 E&M codes

We have identified an increased trend in billing emergency department level 5 evaluation and management (E&M) codes. To help ensure documentation meets or exceeds the components necessary to support its billing, beginning September 1, 2019, we will initiate postpay reviews for emergency department professional claims billed with level 5 99285 or G0384. Emergency department professional claims with the highest potential for up-coding will be selected.

 

We will request documentation for identified claims. Professional reviews will evaluate the appropriate use of the emergency department level 5 code based on the American Medical Association CPT coding manuals and Anthem guidelines. Reimbursement should be based on the emergency department E&M code the submitted documentation supports.

 

Please note: These coding reviews are not related to any prior notification reviews which examine the appropriate use of emergency departments for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patients utilize emergency room services.

 

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