← Back to list
Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services
Act
by Sep 28, 2026
Effective date
Sep 28, 2026
Identified
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.
Get alerts when payers change rules like this one
We check Ambetter and other payers every day and email you when a change matches your specialty and state.
Get Ambetter alertsPolicy Monitoring is free. No card required.
What to do
by Sep 28, 2026 · 6 steps
01Billing team and ED providers must audit current E&M coding practices for outpatient emergency department facility charges.
02Review 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.
03Providers must document facility resource intensity in medical records.
04Update billing guidance to clarify distinction between provider E&M codes (based on physician work) and facility E&M codes (based on resources).
05Ambetter will automatically recode claims not meeting resource criteria, resulting in payment reductions if current coding practices are overcoded.
06Proactively align coding to avoid claim adjustments.
Original notice
Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Provider Notification: Cotiviti ED Leveling - FacilityHighEffective Nov 1, 2026 · CodingEffective November 1, 2026, Ambetter Health will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.HighEffective Nov 1, 2026 · CodingBrowse every Ambetter change in the policy list