Category: Medicaid

In an ongoing effort to ensure accurate claims processing and payment, Empire BlueCross BlueShield HealthPlus (Empire) is taking additional steps to verify the accuracy of payments made to providers. Beginning on October 27, 2019, Empire will assess selected claims for evaluation and management (E&M) services using an automated analytic solution to ensure payments are aligned with national industry coding standards.


Providers should report E&M services in accordance with the American Medical Association CPT manual and CMS guidelines for billing E&M service codes (Documentation Guidelines for Evaluation and Management).


The level of service for E&M service codes is based primarily on the documented key factors, medical history, examination and medical decision-making. Counseling, coordination of care, the nature of the presenting problem and face-to-face interaction are considered contributing factors. The appropriate E&M level code should reflect and not exceed what is needed to manage the member’s condition(s).


Claims will be selected from providers who, based on a risk adjusted analysis, code a higher level E&M services compared to their peers with similar risk-adjusted members. Individual claims will be identified as over-coded based on a claim specific risk adjusted analysis. If a claim is determined to be over-coded, it will be reimbursed at the fee schedule rate for the appropriate level of E&M for the condition(s) identified. Providers whose coding patterns improve are eligible to be removed from the program.


If providers have medical record documentation to support reimbursement for the originally submitted E&M service, those medical records should be submitted for consideration.


If you have questions, contact your local Provider Relations representative or call Provider Services toll free at 1-800-450-8753.


NYE-NU-0150-19 July 2019

Featured In:
September 2019 Empire Provider News