Payment policy expands level of service accuracy review
Starting early 2026, evaluation and management services provided outside the emergency department will be re-coded based on submitted diagnosis codes.
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.
Currently, evaluation and management (E&M) services provided by emergency department professionals are re-coded based on submitted diagnosis codes. Starting with dates of service Feb. 1, 2026, non-emergency department E&M claims* will be re-coded based on submitted diagnosis codes. The policies mirror those by Centers for Medicare & Medicaid Services (CMS).
*Some exclusions may apply.
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 re-coding 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 re-coding 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 re-bill. Instead, Geisinger Health Plan will appropriately recode the claim. Your rights to appeal claims remain unchanged.
You may see the below claims adjustment and remittance advice codes if your claim has been adjusted:
- CARC: 150 Payer deems the information submitted does not support this level of service.
- RARC: N10 Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.
Reference Information
Questions about this change?
Call 844-GHP-PROV (844-447-7768).
This Operations bulletin amends the Participating Provider Guide as of Feb. 1, 2026.
