Updates to Evaluation & Management (E&M) Code Billing
Dear Provider,
Aetna Better Health® of Ohio continues its commitment to correct coding and the implementation of programs that support nationally recognized and accepted coding policies and practices. Evaluation and Management (E&M) coding is an area that the Centers for Medicare & Medicaid Services (CMS) has identified as having significant error rates.
What does this change mean for my office?
Starting with claims for dates of service
on or after January 1st 2019, we will evaluate the appropriateness of E&M coding reported using CMS and AMA documentation guidelines for Office Visit codes:
- New Patients CPT codes 99201-99205,
- Established Patients CPT codes 99211-99215, and
- Office Consultations codes 99241-99245.
Based on the outcome of this evaluation, your payment may be adjusted if the information submitted on the claim does not support the level of service billed.
If your claim is adjusted for this reason, you will see the follow remittance information:
- CARC 252 - an attachment / other documentation is required to adjudicate this claim / service
- RARC M127 - missing patient medical record for this service
- N183 - ALERT: - this is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.
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