Claims Payment Policy Update Notification CC.PP.072

9/14/2026

Thank you for your continued partnership with Wellcare. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Wellcare will be implementing effective with Dates of Service starting 11/01/2026. Posted policy on site contains a revision log explaining the updates that occurred in the annual review.

Policy Number

Policy Name

Policy Summary

Lines of Business

CC.PP.072

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.

Policy/Criteria
The health plan does not reimburse facility evaluation and management (E/M) charges billed in conjunction with a treatment room revenue code as these services do not represent a specific procedure performed in a treatment room. Billing treatment room revenue codes is incorrect coding when reported for office-based evaluation and management services. The health plan will reimburse facility treatment room services directly related to the procedure(s) that are provided on the same day in which the treatment is rendered.

Applies to: Type of Bill 13X

Reimbursement Guidelines
The health 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 service according to the application criteria mentioned in this policy.

Any service line reported incorrectly will be denied for reimbursement.

Medicare

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

Sincerely,
Wellcare