Medicare AdvantageBilling CodesHigh impact
Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services
Ambetter·NC · Emergency Medicine·Coding
Effective date
Sep 28, 2026
We identified it
Aug 26, 2026
Summary
Effective September 28, 2026, Ambetter of North Carolina will implement automated recoding of emergency department E&M facility service claims to appropriate CPT levels based on resources utilized (nursing time, clinical staff, supplies, equipment, overhead), not physician cognitive work. Claims billed at higher levels than supported by facility resources will be automatically downleveled to the highest level meeting criteria under their peer risk adjustment process.
Action Required
By September 28, 2026: Billing team and ED providers must audit current E&M coding practices for outpatient emergency department facility charges. Review all ED E&M codes (99281-99285 facility component) to ensure coding reflects actual facility resources utilized (nursing time, clinical staff effort, supplies, equipment, overhead) rather than physician complexity. Providers must document facility resource intensity in medical records. Update billing guidance to clarify distinction between provider E&M codes (based on physician work) and facility E&M codes (based on resources). Ambetter will automatically recode claims not meeting resource criteria, resulting in payment reductions if current coding practices are overcoded. Proactively align coding to avoid claim adjustments.