22-268 Bill E&M Services Correctly with New Payment Policy to Avoid Payment Delays
Date: 04/04/22
The policy addresses E&M services billed with treatment room revenue codes
California Health & Wellness Plan (CHWP) is publishing a payment policy that is effective June 8, 2022.
Billing codes
CHWP’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.
CHWP will deny reimbursement for any service line reported incorrectly.
Policy guidelines
CHWP 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.
CHWP 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
Access payment policies simply online on the provider website. Select For Providers > Provider Resources > Clinical & Payment Policies.
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, independent practice associations, hospitals and ancillary providers |
Additional information
Providers are encouraged to access CHWP’s 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 CHWP at 877-658-0305.