Emergency Department Evaluation and Management Coding Review Coming Soon

We’re implementing a new automated review process to help ensure ED facility claims containing Evaluation and Management (E&M) service are coded and reimbursed consistently, based on the diagnoses and other services billed for outpatient ED visits.

What’s changing

We will begin using Lyric’s ED Facility Coding solution, a real-time (pre-payment) claim editor that reviews outpatient ED Service claims. The tool analyzes diagnosis information, ED E&M service level, and other services billed on the claim to determine the appropriate ED E&M visit level.

What this means for you

• Outpatient ED E&M service claims may be adjusted to a different ED E&M visit level based on the clinical information and services billed.
• If the level of service was adjusted, the billed and adjusted service codes will be displayed within Availity along with the reason for the change.
• For claims related to percent of billed charges contracts, the ED E&M visit will be denied requiring a re-bill of the service with the appropriate level of care.
• Claims will be evaluated automatically as part of processing, prior to payment.
• This review is focused on ED facility coding and does not change member eligibility or benefits.

Timeline

• Provider payment policy notification: April 2, 2026
• Targeted start date: July 3, 2026

What you can do now

• Review ED E&M level of service coding and documentation practices to ensure the diagnosis and services billed support the reported ED visit level.
• Share this update with your revenue cycle, coding, and compliance teams.
• Please use the Clear Claim Connection (C3) claims tool within Availity Essentials to obtain guidance in determining appropriate level of service billing (please remember to populate all procedures that will be or were performed, to produce the most accurate guidance).
• Watch for additional details, including any FAQs and reconsideration/appeal guidance.

Questions

If you have questions, please contact your Premera provider representative.