Policy Updates Reimbursement PoliciesAnthem Blue Cross and Blue Shield | CommercialMarch 31, 2023

Reimbursement policy update: Documentation and Reporting Guidelines for Evaluation and Management Services - Professional

Effective April 1, 2023, Anthem Blue Cross and Blue Shield will update the documentation and reporting guidelines for Evaluation and Management Services — Professional reimbursement policy to align with CMS guidance for documenting evaluation and management (E/M) services and determining E/M service level. This update includes CMS’ adoption of the American Medical Association (AMA) Current Procedural Terminology® (CPT) 2023 code changes for Other E/M Services (except for prolonged services), as detailed below.

Adoption of 2023 code changes

As of January 1, 2023, CMS adopted the revised AMA CPT codes for Other E/M Services (except for prolonged services). These code changes include:

  • Allowing total time to be used for determining service level for timed visits.
  • Requiring a medically appropriate history and/or exam, rather than using history and exam to determine visit level.
  • Merger of hospital inpatient and observation visits code sets.
  • Merger of domiciliary, rest home, or custodial care and home visits code sets.
  • New descriptor times (where relevant).
  • Revised CPT E/M guidelines for levels of medical decision making (MDM).

Other E/M Services include:

  • Inpatient and observation visits.
  • Emergency department visits.
  • Nursing facility visits.
  • Domiciliary or rest home visits.
  • Home visits.
  • Cognitive impairment assessment.

Documentation requirements for using time to determine E/M service

This reimbursement policy is also being updated to clarify documentation requirements when evaluating an E/M service based on total time. While the use of time for determining E/M service is intended to ease the reporting burden on providers, documentation must still be sufficient to establish medical necessity and exact time. Documentation should describe the activities performed during the period of E/M service and the total time must be specifically stated, rather than stated as an approximate range. If the documentation requirements are not met for the use of time in establishing the level of service, then the claim will be evaluated using MDM criteria.

 Reference

Medicare Physician Fee Schedule Final Rule Summary: CY 2023. MLN Matters Number: MM12982.

https://www.cms.gov/files/document/mm12982-medicare-physician-fee-schedule-final-rule-summary-cy-2023.pdf

For specific policy details, visit the reimbursement policy page at anthem.com.

MULTI-BCBS-CM-021000-23-CPN20623

PUBLICATIONS: April 2023 Provider News - Maine