Emergency Department Evaluation and Management Claim Adjustment
Defines Fidelis Care's process for pre-payment review and adjustment of Emergency Department Evaluation and Management (E&M) professional claims to ensure billed E&M levels match documentation; applies to providers billing ED E&M CPT codes for Fidelis Care members.
No material clinical or coverage changes in this revision.
Emergency Department E&M Claim Adjustment Criteria
ED E&M claim adjustment criteria
Claims handling and adjustment approach for ED E&M professional services billed to Fidelis Care.
ED E&M Codes and Minimum Assigned Levels
| 99281 | Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional. |
| 99282 | Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward 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. |
| 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. |
Provider Notice: Review and Potential Adjustment Process
Pre-payment claims review
Fidelis Care will conduct a pre-payment claims review (after services are rendered, but prior to claims payment) to determine the correct level of evaluation and management coding. The review uses a coding algorithm and nurse review process that evaluates each diagnosis billed, historical claims, and other claims information to assign a maximum payable E&M level per diagnosis.
- Review occurs after services are rendered but before claims payment.
- Coding algorithm and nurse review evaluate each diagnosis code, historical claims, and other claims information (including additional testing/procedures).
- When multiple diagnoses are billed, the algorithm assigns a maximum level of service to each diagnosis.
Potential claim adjustment (no denial solely for policy)
E&M services will not be denied solely due to this policy; however, billed E&M services will be reviewed and may be reduced based on the level of service billed on the claim. The review may assign a lower maximum payable level consistent with the algorithm and minimum level rules.
- Minimum assigned levels: level 3 for five-level E&M categories and level 2 for three-level E&M categories.
- E&M categories have assigned values and may be adjusted downward to the appropriate level.
Key Definitions
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.