Leveling of Care EM Overcoding

Date: 08/08/25

Wellcare is committed to continuously improving its claims review and payment processes. This letter is to notify you that effective 09/01/2025, we will begin applying national CPT billing guidelines for the appropriate coding of physician emergency department Evaluation and Management (E&M) code levels.

Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to practitioners.  The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.  

Overview of Wellcare E&M Program; 

• Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim. 
• 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 the Centers for Medicare and Medicaid Services (CMS') guidelines for billing E&M service codes; “Documentation Guidelines for Evaluation and Management”.  The proper reporting of E&M Services enables Wellcare to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.  

Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case. 

Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members.