22-267 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.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
The policy addresses E&M services billed with treatment room revenue codes
Health Net*, on behalf of CalViva Health, is 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
- Log in to provider website.
- Select Provider Library under Quick Links.
- Once in the Provider Library, select Medi-Cal, 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
- Go to provider library.
- Once in the Provider Library, select Medi-Cal, 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 the 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 the provider website under Quick Links, or go directly to provider library.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.