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BCBS MichiganCommercial · Reimbursement · Coding · MI · Emergency MedicineHigh impact

We’re making updates to the Emergency Department Facility Evaluation and Management coding policy

Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Jul 23, 2026

Summary

Blue Cross Blue Shield of Michigan is expanding prepayment review of emergency department claims to include E/M levels 2-5 (previously only levels 4-5 were reviewed) effective October 1, 2026. Claims not meeting policy criteria will be automatically adjusted downward to the appropriate level. Fee-schedule hospitals will see automatic adjustments; percent-of-charge hospitals must resubmit adjusted claims for payment.

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What to do

by Sep 30, 2026 · 7 steps
01Billing team must prepare for expanded prepayment review of ED E/M claims levels 2-5.
02Update billing staff on new EDCA program review scope expansion.
03For fee-schedule hospitals: No action required—Blue Cross will automatically adjust claims; monitor vouchers for CO45 adjustment codes and verify accuracy of level adjustments.
04For percent-of-charge hospitals: Establish internal process to receive Blue Cross remittance vouchers with adjustment recommendations, correct claim coding/charges, and resubmit to Blue Cross.
05For all facilities: Prepare medical records documentation to support reconsideration requests if needed, ensuring documentation includes non-billable resource intensity, operational complexity, staff resource utilization, technology use, and evidence that intensity exceeded typical representation.
06Do NOT submit reconsideration requests based on disagreement with ED leveling methodology, internal facility scoring tools, general complexity statements, or appeals without new documentation.
07Monitor initial claim adjustments starting October 1, 2026, and track adjustment patterns to identify coding gaps.

Original notice

We’re making updates to the Emergency Department Facility Evaluation and Management coding policy
bcbsm.com · Always check the source before changing claims.
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BCBS Michigan policiesMI policy changesEmergency Medicine

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