Review of professional claims with emergency room level 5 E/M codes

Anthem Blue Cross and Blue Shield (Anthem) has identified an increasing trend in the billing of emergency room (ER) level 5 Evaluation and Management (E/M) codes. To help manage increasing healthcare costs, beginning August 1, 2019, Anthem will initiate the post-pay review of professional ER claims billed with level 5 E/M Codes (99285 or G0384) to ensure documentation meets or exceeds the components necessary to support its billing. Professional ER claims with the highest potential for up-coding will be selected.

 

Anthem will request documentation for identified claims, and level 5 ER professional reviews will evaluate the appropriate use of the level 5 ER code based on the AMA CPT coding manuals, and Anthem guidelines. Reimbursement will be based on the ER E/M code the submitted documentation supports.

 

Please note, these coding reviews are not related to any prior notifications of reviews which examine the appropriate use of ERs for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patient utilize emergency room services.