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New post-pay review and education program for E&M codes

02/01/2019

We work to actively promote correct claim coding, including the appropriate use of Evaluation and Management (E&M) codes. To support this effort and our goal of improved physician education, we are implementing a post-pay review and education program for providers. Providers who appear to bill a higher volume of high level evaluation and management codes in comparison to their peers will be identified as part of this program.

Providers who are identified will receive a request for medical records. We will review the claim submissions along with the medical records to determine if the appropriate E&M level was billed.

If we determine that the medical documentation submitted supported an E&M code of a lower level than what was originally paid, we will adjust the claim and recoup the amount. If a provider fails to submit the supporting documentation requested, we will also adjust the claim and recoup the amount. In either case, a remittance advisory describing the payment details of the adjusted claim will be sent to the mailing address we have on file for the provider.

Please visit our website for more specific guidelines.