Medicare AdvantageBilling CodesHigh impact
Important CC.PP.80 Policy Update
Ambetter·AR · Emergency Medicine·Coding
Effective date
Oct 1, 2026
We identified it
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.
Action Required
By September 30, 2026: Billing team must prepare for implementation of Arkansas Health & Wellness CC.PP.80 policy on emergency department E&M recoding. REQUIREMENTS: (1) Audit current ED E&M coding practices to identify potential overcoding based on facility resource utilization rather than provider cognitive work; (2) Train 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); (3) Review and update billing system logic to apply the peer risk adjustment process for determining the highest appropriate E&M level; (4) Establish internal monitoring for ED E&M submissions to catch high-coding practitioners before claim submission; (5) Contact Arkansas Health & Wellness at 1-800-294-3557 with questions before the effective date. CONSEQUENCES: 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.