Enhancing accuracy in evaluation and management services claims

New measures for E/M claim evaluations

To promote accurate claims processing and payment, Anthem is implementing additional measures to evaluate selected claims for E/M services submitted by professional care providers. Starting on November 1, 2025, we will review whether the coding on these claims aligns with national industry coding standards.

Improving the accuracy of claims processing

Care providers should report E/M services according to the American Medical Association (AMA) CPT^® manual and CMS guidelines for billing E/M service codes. The appropriate level of service is primarily determined by the documented medical history, examination, and medical decision‑making. Counseling, coordination of care, the nature of the presenting problem, and face‑to‑face time are also considered contributing factors. The coded service should accurately reflect, and not exceed, what is necessary to manage the member’s condition(s).

Claims selection and review

Claims will be selected from care providers identified as coding at a higher E/M level compared to their peers with similar risk‑adjusted members. Prior to payment, Anthem will review the selected E/M claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the submitted E/M code level is higher than the E/M code level supported by the claim. If the submitted E/M code level exceeds the E/M code level supported by the claim, Anthem reserves the right to:

• Consider the claim ineligible for reimbursement and ask for the resubmission of the claim with the correct E/M level.
• Suspend the claim and ask for documentation supporting the billed E/M level.
• Adjust the reimbursement to align with the lower E/M level supported by the claim.

The maximum level of service for E/M codes will depend on the complexity of medical decision‑making and will be reimbursed at the appropriate E/M code level and fee schedule rate.

This initiative will not affect every level four or five E/M claim. Care providers whose coding patterns improve and are no longer classified as outliers are eligible for removal from the program.

Dispute resolution process

Care providers who believe their medical record documentation justifies reimbursement for the initially submitted level of the E/M service will have the opportunity to use the dispute resolution process, which involves submitting documentation along with the dispute. Care providers can follow the dispute process detailed in the provider manual available online.

Conclusion

These measures enhance our commitment to transparency and fairness, ensuring that all claims are processed accurately and equitably. With your support, we can consistently progress towards a future of shared success.