Anthem Blue Cross to review level 5 emergency room claims

CAL/AAEM News Service calaaem.news.service1 at gmail.com
Tue Feb 16 13:06:40 PST 2016


       

 

February 16, 2016

 

Anthem Blue Cross to review level 5 emergency room claims

 

 

 <http://www.cmanet.org/cpr/cpr-archives/2016/february-2016/#4> California
Medical Association

 

 

Anthem Blue Cross announced in its December Professional Network Update
that, beginning January 1, 2016, it will initiate a pre-payment review of
level 5 emergency department visits billed with CPT 99285 or G0384. 

 

Anthem has advised CMA that it will focus on level 5 emergency department
visits that are billed in combination with diagnosis codes that "are an
unlikely combination for high level visits." The payor will exclude claims
billed with critical care, observation or inpatient admissions.

 

Claims with CPT codes 99285 and G0384 that are selected by Anthem for
pre-payment review will be pended and, if records are not included with the
claim, a request for medical records will be generated. Anthem will review
the records to verify that the documentation supports the level of service
billed per CPT guidelines.

 

Anthem has advised CMA that if it does not believe, after review of the
records, that the documentation supports the level billed, it will pay the
claim based on the evaluation and management (E/M) level supported. The
explanation code will reflect this action.

 

Providers will have the ability to dispute the findings through the normal
provider dispute resolution process.

 

 

 

Jeff Wells
Deputy Editor, CAL/AAEM News Service

 

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service



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