22-266 Bill E&M Services Correctly with New Payment Policy to Avoid Payment Delays

Date: 04/04/22

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

The policy addresses E&M services billed with treatment room revenue codes

Health Net* and Wellcare By Health Net are publishing a payment policy that is effective June 8, 2022.

Billing codes

The Plan’s code editing software will evaluate claims billed with revenue codes 760, 761 and 769 that are billed in conjunction with an evaluation and management (E&M) service according to the application criteria mentioned in the policy.

The Plan will deny reimbursement for any service line reported incorrectly.

Policy guidelines

The Plan does not reimburse for facility E&M charges billed in conjunction with a treatment room revenue code. These services do not represent a specific procedure performed in a treatment room. Use of billing treatment room revenue codes is incorrect coding when reported for office-based E&M services.

The Plan will reimburse facility treatment room services directly related to the procedure(s) that are provided on the same day on which the treatment is rendered.

View polices online in the Provider Library

Use one of the two options below to access the Provider Library.

Option 1 – Log in to the provider website

1. Log in to provider website.
2. Select Provider Library under Quick Links.
3. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.

Option 2 – Go directly to the Provider Library

1. Go to provider library.
2. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.

Policy chart

The following table lists the policy number and name, a description of the policy and applicable providers.

Policy number	Policy name	Description	Applicable providers
CC.PP.071	E&M Services Billed with Treatment Room Revenue Codes	Treatment room and specialty services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting. The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus. Treatment room services are outpatient services furnished on hospital premises which require the use of a bed and periodic monitoring for a relatively brief episode of time to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room, as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia. Applies to type of bill 130x.	Physicians, participating provider groups, hospitals and ancillary providers

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library after logging in to Health Net’s provider website under Quick Links, or go directly to provider library.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by phone or through the Health Net provider website.