Reimbursement policy update: Emergency Department: Leveling of Evaluation and Management Services (Facility)
- Deny the claim and request resubmission at the appropriate level or request the provider submit documentation supporting the level billed
- Adjust reimbursement to reflect the lower ED E&M classification
- Recover and/or recoup monies previously paid on the claim in excess of the E/M code level supported
Facilities that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process in accordance with the terms of their contract. Claims disputes require a statement providing the reason the intensity/complexity would require a different level of reimbursement and the medical records which should clearly document the facility interventions performed and referenced in that statement.
October 2020 Anthem Provider News - Georgia