As the physician of a member who has coverage under Affordable Care Act (ACA) compliant plans, you play a vital role in accurately documenting the health of the member to ensure compliance with ACA program reporting requirements. When members visit your practice, we encourage you to document ALL of the members’ health conditions, especially chronic diseases.  Ensuring that the coding on the claim submission is to the greatest level of specificity can help reduce the number of medical record requests from us in the future.


Please ensure that all codes captured in your EMR system are also included on the claim(s), and are not being truncated by your claims software management system.  For example, some EMR systems may capture up to 12 diagnosis codes, but the claim system may only have the ability of capturing 4.  If your claim system is truncating some of your codes, please work with your vendor/clearing house to ensure all codes are being submitted.


Reminder about ICD-10 coding


As you may be aware, the ICD-10 coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits.  Additionally, Anthem uses ICD-10 codes submitted on claims to monitor health care trends and costs, disease management, and clinical effectiveness of management of medical conditions.  The Centers for Medicare and Medicaid Services (CMS) uses ICD-10 as part of the risk adjustment program created under the ACA to determine the risk score associated with a member’s health.


Using specific ICD diagnosis codes will help convey the true complexity of the conditions being addressed in each visit.

  • Code the primary diagnosis, condition, problem or other reason for the medical service or procedure.
  • Include any secondary diagnosis codes that are actively being managed.
  • Include all chronic historical codes, as they must be documented each year pursuant to the ACA.  (E.g.: An amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).


If you are interested in having a coding training session conducted by an Anthem coding auditor, please contact our Commercial Risk Adjustment Representative who supports your area:

Featured In:
November 2019 Anthem Provider News and Important Updates - Colorado