New Payment Integrity Prospective Concept: Evaluation & Management (E/M) Over Coding

Blue Cross Blue Shield of North Dakota (BCBSND) wants to inform providers of a new prospective payment integrity concept being implemented on April 23, 2023, for Commercial and Medicaid Expansion claims.

Evaluation & Management (E/M) CPT codes with a level 4 and 5 will be reviewed for outliers identified within the same performing provider specialty. Claim data is reviewed based on the submitted diagnosis codes; medical records will not be requested. Should the data review determine the E/M service is overcoded, the line will be recoded and reimbursed at the recommended level.

An example of this may look like CPT code 99285 billed but is recoded and reimbursed as CPT code 99284.

Providers will receive results of the review on their Electronic Remittance Advice (ERA), which will reflect the new code and reimbursement. If a provider disagrees with a payment determination, a reconsideration can be requested using the appeal form. More information regarding the ERA notification information and reconsiderations can be found on the BCBSND website BCBSND Prospective (pre-pay).

Providers should contact BCBSND Provider Services with questions. Please do not contact Cotiviti for claim processing questions on prospective concepts.