New payment policy addresses ER level of service accuracy

We’ve noticed a growing trend of higher-than-expected levels of service (LOS) in emergency room (ER) evaluation and management (E&M) visits.

Although the Centers for Medicare & Medicaid Services does not have specific coding instructions for ER facilities, guidance indicates the LOS should accurately reflect the ER facility resources and not the physician resources.

E&M codes for providers are reported to capture the complexity and intensity of the provider’s work. However, E&M codes for facilities are reported for the amount and intensity of resources the facility uses to provide patient care.

What’s changing?

Beginning with dates of service Jan. 1, 2025, Geisinger Health Plan and our claims review partners at Cotiviti will use these guidelines to determine whether an ER facility E&M LOS is coded correctly based on documentation of other associated services during the ER visit. Our analysis will focus on high-level ER facility codes to ensure the CPT codes reported and billed support the documentation.

If E&M LOS is not accurately coded, claims will not be denied and there will be no obligation to rebill. Instead, Geisinger Health Plan will appropriately recode the claim. Your rights to appeal claims remain unchanged.

See the below claims adjustment and remittance advice codes if your claim has been adjusted:

• CARC: 150 Payer deems the information submitted does not support this level of service.
• RARC: N10 Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review. 

Questions about this change?