Empire BlueCross BlueShield (Empire) continues to be dedicated to delivering access to quality care for our members, providing higher value to our customers and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, Empire is taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers. Beginning on December 1, 2020, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.


Providers should report E/M services in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The appropriate level of service is based primarily on the documented medical history, examination and medical decision-making. Counseling, coordination of care, the nature of the presenting problem and face-to-face time are considered contributing factors. The coded service should reflect and not exceed that needed to manage the member’s condition(s).


Claims will be selected from providers who are identified as coding at a higher E/M level as compared to their peers with similar risk-adjusted members. Prior to payment, Empire may review E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, Empire reserves the right to: 

  • Deny the claim and request resubmission of the claim with the appropriate E/M level;
  • Pend the claim and request documentation supporting the E/M level billed; and/or
  • Adjust reimbursement to reflect the lower E/M level supported by the claim.


The maximum level of service for E/M codes will be based on the complexity of the medical decision-making, and reimbursed at the supported E/M code level and fee schedule rate.


This initiative will not impact every level four or five E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.


Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).


If you have questions regarding this program, contact your contract manager or Network Relations.


EBSCRNU-0127-20 August 2020



Featured In:
October 2020 Empire Provider News