Payment policy addresses ER level of service accuracy

Over the past several years, Geisinger Health Plan has been implementing payment policies that reflect guidelines set forth by industry authorities. Our goal is to process claims consistently and in accordance with best practice standards. Beginning with claims with dates of service starting Aug. 1, 2025, we’ll be instituting new payment policies for recoding evaluation and management (E&M) services based on diagnosis. The policies mirror those by Centers for Medicare & Medicaid Services (CMS).

What's changing?

The new policies will define diagnosis requirements for the following:  

• E&M code levels

According to the CMS policy and the AMA CPT codebook, a higher level of evaluation and management should not be reported when a lower level of service is warranted. The level of service should be documented during or soon after it is provided.

E&M recoding for this policy occurs based on the valid diagnosis codes submitted for an E&M code. Maximum levels of service are associated with diagnosis codes based on the severity of the diagnoses. When a provider submits a level of service that exceeds the maximum level of service allowed, the E&M code is lowered to match the maximum level of service allowed. When multiple diagnosis codes are billed, the recoding will be based on the highest level of service associated with one or more of the diagnosis codes billed.

How claims will be handled

If E&M is not accurately coded, claims will not be denied and there will be no obligation to rebill. Instead, Geisinger Health Plan will appropriately recode the claim. Your rights to appeal claims remain unchanged.