2026/7/28
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Posted by Provider Relations
Effective September 1, 2026, Fidelis Care will implement the Leveling of Care: Emergency Department Evaluation and Management (E/M) Overcoding for Facility Services Policy (CC.PP.80) for applicable lines of business.
This policy is designed to help ensure facility Emergency Department E/M coding accurately reflects the level of resources used during a patient visit. Claims will go through a review prior to payment to determine if the billed level of service is supported by the claim evidence and resources.
This approach is consistent with national billing guidance and industry oversight priorities. Both the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E/M services are among the services most likely to be incorrectly coded, which can result in improper payments. The OIG has also recommended that payers continue educating providers on E/M coding and documentation and develop programs to review E/M services billed by high-coding practitioners.
For Emergency Department facility E/M codes, the level of service is based primarily on the resources used by the facility and Emergency Department staff. Facility resources may include nursing time, clinical staff effort, supplies, equipment, overhead, testing, monitoring, and interventions directly related to the patient’s care. This is distinct from professional E/M coding, which captures the clinical complexity and intensity of the provider’s work.
Providers are encouraged to maintain clear documentation of all facility resources, services, testing, monitoring, and interventions provided during ED encounters to support the level billed. Providers retain the right to appeal and submit additional documentation for review when necessary.
For questions regarding this policy, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.