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AmbetterExchange · Billing Codes · Coding · AR · Emergency MedicineHigh impact

Important CC.PP.80 Policy Update

Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Aug 26, 2026

Summary

Arkansas Health & Wellness will begin applying national CPT billing guidelines for outpatient emergency department E&M codes effective October 1, 2026, focusing on facility resource utilization rather than provider complexity. The policy will recode claims to the appropriate E&M level based on resources used (nursing time, clinical staff, supplies, equipment) and allow reimbursement at the highest level for which criteria are met. This addresses CMS and OIG concerns about E&M overcoding in emergency departments.

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What to do

by Sep 30, 2026 · 7 steps
01Billing team must prepare for implementation of Arkansas Health & Wellness CC.PP.80 policy on emergency department E&M recoding.
02Audit current ED E&M coding practices to identify potential overcoding based on facility resource utilization rather than provider cognitive work.
03Train billing staff and providers on the distinction between facility E&M codes (based on resources: nursing time, clinical staff effort, supplies, equipment, overhead) versus professional provider codes (based on clinical complexity).
04Review and update billing system logic to apply the peer risk adjustment process for determining the highest appropriate E&M level.
05Establish internal monitoring for ED E&M submissions to catch high-coding practitioners before claim submission.
06Contact Arkansas Health & Wellness at 1-800-294-3557 with questions before the effective date.
07CONSEQUENCES: Claims coded incorrectly to higher E&M levels than supported by facility resource documentation will be recoded by the payer, resulting in reduced reimbursement and potential audit exposure.

Original notice

Important CC.PP.80 Policy Update
ambetterhealth.com · Always check the source before changing claims.
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Ambetter policiesAR policy changesEmergency Medicine

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