Thank you for your continued partnership with Wellcare. We are committed to continuously evaluating and improving payment integrity processes.
Effective June 1, 2026, we will apply national CPT billing guidelines for the appropriate coding of physician emergency department Evaluation and Management (E&M) code levels.
The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector Generals (OIG) have documented that E&M services are highly likely to be incorrectly coded, resulting in improper payments. The OIG recommended continued support and education about coding and documentation of E&M services along with programs to review E&M services billed by high-coding practitioners.
Overview of Wellcare’s E&M Program
- Evaluates and reviews only high-level E&M services based on diagnostic information on claims
- Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service
- Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process
Providers should report E&M service in accordance with American Medical Association’s (AMA) CPT Manual and CMS billing codes guidelines— Documentation Guidelines for Evaluation and Management.
This will allow Wellcare to apply reimbursement more precisely per coding guidelines and ensure that an accurate record of patient care history is maintained.
Determinations will be made according to accepted standards of medical practice and the medical circumstances of the individual case.
- Leveling of Care: Office-based Evaluation and Management Over-coding (CC.PP.066) (PDF)
- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Professional Services (CC.PP.076) (PDF)
Thank you again for your collaboration and continued participation in our ongoing efforts to render quality healthcare to our members.
