Dear Provider,
WellCare Health Plans, Inc. is committed to continuously improving its claims review and payment processes. This letter is to notify you that effective November 29, 2020, we will begin applying coding edit guidelines for the appropriate coding of Evaluation and Management (E&M) code levels based on WellCare’s E&M Program.
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 high-level E&M services for high-coding practitioners, which appear to have been incorrectly coded based upon diagnostic information that appears on the claim, and peer comparison.
- Applies the relevant E&M policy and recoding of the claim line to the proper E&M level of service.
- Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our risk adjustment process.
Providers should report E&M services in accordance with the American Medical Association’s (AMA’s) 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 Health Plans, Inc. to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.
Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations – with reference to accepted standards of medical practice and the medical circumstances of the individual case.
Thank you for your cooperation. If you have any questions or need more information, please contact your Provider Relations representative. Dispute rights provided.
Sincerely,
Provider Operations Payment Integrity
CPT® is a registered trademark of the American Medical Association.
