CurrentArizona Complete HealthPolicy CC.PP.076

Leveling of Care: Emergency Department Evaluation and Management Overcoding for Professional Services

Defines the payer's prepayment claims review and reimbursement adjustments for professional emergency department (ED) evaluation and management (E&M) services when billed levels exceed what documentation and claim data support; applies to physicians and qualified healthcare professionals submitting ED professional claims.

Policy Summary

PayerArizona Complete Health

PolicyLeveling of Care: Emergency Department Evaluation and Management Overcoding for Professional Services

Policy CodePolicy CC.PP.076

Change TypeNon-material editorial revision

Effective Date

Next Review Date

Key ActionAutomated pre-payment claims review may adjust ED E&M reimbursement down to as low as 99283 when documentation and claim data do not support the billed level.

SourceLink

POLICY UPDATE CHANGES

Updated language in Policy Overview and removed 'hospital observation services', added language under Reimbursement regarding coding validation.

99284,99285ED E&M codes reviewed on claims

99283Minimum reduced level

pre-paymentClaims review timing

professionalApplies to

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ED E&M Leveling Criteria

Claims review and adjustment criteria for ED professional E&M services:

Automated pre-payment algorithm selects professional ED service lines for clinical validation when high-level ED procedure codes are billed or diagnosis codes warrant review.

Data used for coding validation includes current claim information, member claim history, and corresponding facility claim resources such as labs, radiology, pharmaceuticals, and specialty provider interpretations of diagnostic services.

If documentation and claim data do not support the billed ED E&M level, reimbursement will be adjusted to the appropriate level reflecting services performed; adjustments will not result in denial but may reduce the paid level down to a minimum of 99283.

This policy applies to physician and other qualified health care professionals providing face-to-face ED professional services reporting E&M CPT codes; it applies to professional claims only (does not apply to facility claims).

Providers should follow AMA CPT and CMS guidelines for selecting E&M levels; documentation must support the level billed (history, examination, medical decision making).

Codes and Allowable Reduced Level

ED E&M codes referencedCPTCovered

99284	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
99285	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
99283	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making (minimum reduction target).

ED E&M codes referenced (summary)mixed

99284	ED visit, moderate level of medical decision making
99285	ED visit, high level of medical decision making
99283	ED visit, low level of medical decision making (minimum reduction target)

Minimum allowable reduced ED level

Minimum reduced ED level99283 (ED visit — low level of medical decision making) may be the lowest level the claim can be adjusted to during prepayment leveling.

Applies toProfessional emergency department E&M service lines flagged by the prepayment algorithm (e.g., billed 99284, 99285)

Adjustment outcomeReimbursement may be adjusted down to level 99283 when documentation and claim data do not support the billed higher ED E&M level; reductions will not result in denial.

Prepayment Validation and Billing Impact

Prior Authorization

Prepayment clinical validation may adjust ED E&M reimbursement (minimum 99283)

The health plan will run an automated, pre-payment claims review to identify professional ED claims for additional clinical validation; if the billed ED E&M level is not supported by the claim and related documentation, reimbursement may be adjusted (not denied) down to a minimum of 99283.

Pre-payment algorithm evaluates diagnosis codes and high-level ED procedure codes (99284, 99285) at the service line level to select claims for clinical validation.
Coding validation includes current claim data, member claim history, corresponding facility claim resources (labs, radiology, pharmaceuticals), and specialty provider interpretations.
Reductions will not result in denial but may lower reimbursement to as low as 99283.

Key Terms

Overcoding — definition and context

DefinitionOvercoding: billing procedure codes at a higher level than what is warranted by the clinical documentation.

Context — detectionThe prepayment coding algorithm evaluates diagnosis codes and high-level ED procedure codes to select claims for clinical validation when overcoding is suspected.

Context — consequenceIf documentation and claim data do not support the billed level, reimbursement may be adjusted to the appropriate level rather than denied.

Evaluation and Management (E&M) — definition and components

DefinitionEvaluation and Management (E&M): medical coding to describe patient encounters; used for reimbursement by Medicare, Medicaid, and commercial insurers.

Key componentsHistory, examination, and medical decision making are the three primary components used to select the appropriate E&M level; all must meet or exceed requirements for a given level.