Claims & Payment Policy: E&M Services Billed with Treatment Room Revenue Codes

Dear Provider,

Thank you for your continued partnership with Centene/Wellcare Health Plans. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform providers that the Health Plan is implementing the following policy for (E&M Services Billed with Treatment Room Revenue Codes with an effective date as of May 1, 2022.

Summary of Policy:

Policy Number

Policy Name

Policy Description

Lines of Business

CC.PP.071

CC.PP.072 (Medicare)

E&M Services Billed with Treatment Room Revenue Codes

The Health Plan does not reimburse for facility evaluation and management (E/M) charges billed in conjunction with a treatment room revenue code as these services do not represent a specific procedure performed in a treatment room. Billing treatment room revenue codes is incorrect coding when reported for office-based evaluation and management services.

Medicaid, Medicare, Marketplace

Policy Number

Edit Name/Rationale

Edit Description

IH/CE Code

Lines of Business

CC.PP.071

& CC.PP.072 (Medicare)

Inappropriate treatment room procedure

The Health Plan’s code editing software will evaluate claims billed with revenue codes 760, 761 and 769 that are billed in conjunction with an evaluation and management service according to the application criteria mentioned in this policy.

CE526

Medicaid, Medicare, Marketplace

What does this mean for providers?

The Health Plan is committed to assisting the provider during this time of adjustment.

If a provider does not agree with the Health Plan’s decision, they may dispute or appeal the denial. The Health Plan will require medical records that substantiate provider billing.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.