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Emergency Department Evaluation and Management Over-coding for Facility Services

Fecha: 14/05/26

Sunflower is committed to continuously improving its claims review and payment processes. This letter is to notify you that effective July 1, 2026, we will begin applying national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.

Both 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 practitioners. The OIG has also recommended that payers continue to help educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.

Overview of Sunflower E&M Program; 

  • Applies the relevant E&M policy and recoding of 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 is 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 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 the care of the patient. 

Policy Number: CC.PP.80
Policy Name: Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services
Line of Business Impacted: Medicare, Marketplace

EX Code: EXLc

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 questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call us at the numbers below:



Ambetter from Sunflower Health Plan is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in the Kansas Health Insurance Marketplace. ©2026 Celtic Insurance Company. All rights reserved.