Leveling for Facility Claims

Date: 11/06/26

Ambetter from WellCare of Kentucky will begin applying national CPT billing guidelines for the appropriate coding of outpatient emergency department (ED) Evaluation and Management (E&M) code levels beginning on 12/06/2026.

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

 Overview of Ambetter from WellCare of Kentucky E&M Program

• Applies the relevant E&M policy and recodes the claim line 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 ED Evaluation and Management (E&M) codes is 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 patient care.

You may find a copy of this policy on our website. This updated policy sunsets and replaces the previous Optum EDC Analyzer.

Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members. If you have any questions regarding this notice, please contact your Provider Relations Representative.