Anthem Blue Cross to review level 5 emergency room claims

February 02, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

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. The audit is limited to Anthem Blue Cross Medicare Advantage claims.

Medicare Advantage 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.


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