Reimbursement policy update: Emergency department - leveling of Evaluation and Management services (Facility)*

Effective January 1, 2021, Anthem Blue Cross and Blue Shield (Anthem) classifies with an Evaluation and Management (E&M) code level the intensity/complexity of emergency department (ED) interventions a facility utilizes to furnish all services indicated on the claim. E/M services will be reimbursed based on this classification. Facilities must utilize appropriate HIPAA compliant codes for all services rendered during the ED encounter. If the E&M code level submitted is higher than the E/M code level supported on the claim, we reserve the right to perform one of the following:

• 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

 

Please refer to the Emergency Department: Level of Evaluation and Management Services reimbursement policy for additional details at anthem.com.

 

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.

 

665-1020-PN-CNT