As part of Anthem Blue Cross (Anthem) quality and utilization programs, we routinely analyze the billing patterns of practices in our provider networks using nationally recognized guidelines from the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA). For high-level evaluation and management (E&M) services, the process involves identifying the number of patients receiving high-level E&M services while comparing practices within related specialties. 


Beginning October 10, 2018, Anthem launched a program to help ensure high-level E&M codes are billed appropriately according to CMS and AMA requirements on the claims we receive. During our claims review, Anthem will identify physicians who order high-level E&M services at a significantly greater frequency than that of their peers. Should we find claims with a disproportionate number of high-level E&M services billed as compared to that of other physicians within similar specialties, we will reach out to physicians to provide education about appropriate billing guidelines. Educational outreach will allow for discussion between Anthem and the physician about nationally recognized guidelines and correct coding outcomes.


Those physicians who continue to bill high-level E&M service codes inappropriately may be subject to a decrease in the physician’s fee schedule that is consistent with the terms of the physician’s contract. Such rate adjustments will only be implemented after Anthem has completed provider education and confirmed the accuracy and reliability of billing inaccuracies for high-level E&M service codes.


Physicians can learn more about the details of this program by reviewing the policy, Evaluation for High Utilization of High Level Service Codes by Participating Providers.

Featured In:
December 2018 Anthem Blue Cross Provider Newsletter - California