Effective November 1, 2026, Ambetter Health will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.

Date: 09/02/26

Ambetter Health is committed to continuously improving claims review and payment processes. Effective November 1, 2026, Ambetter will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to providers. The OIG recommended that payers continue to help educate providers on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.

Overview of the E&M Program

• Applies the relevant E&M policy and claim line recoding to the corrected E&M level of service
• Allows reimbursement at the highest E&M service code level for which the criteria are satisfied based on our comparative peer risk adjustment process

According to the Federal Registrar and American College of Emergency Physicians, the level of service for the emergency department (ED) Evaluation and Management (E/M) codes are based primarily on the resources utilized by the facility and staff of the ED.

Facility resources include, but are not limited to, nursing time, clinical staff effort, supplies, equipment, and overhead directly related to the patient’s care, as distinct from the physician’s cognitive work. Professional E/M codes for providers are reported to capture the clinical complexity and intensity of the work performed by the provider; however, E/M codes for facilities are reported for the amount and intensity of resources utilized by the facility to provide the care of the patient. 

Find policy details on Ambetter’s website on the Clinical & Payment Policies web page.

EX Codes:

• AMISYS: EXLc
• Xcelys: LT196

For questions, please contact Ambetter Provider Services call 855-745-5507, Monday through Friday from 8 a.m. to 8 p.m. Thank you for your continued partnership in rendering the highest quality healthcare to our members.