Anthem Blue Cross and Blue Shield (Anthem) continues to be dedicated to delivering access to quality care for our members, providing higher value to our customers, and helping improve the health of our communities. In an ongoing effort to promote accurate claims processing and payment, Anthem is taking additional steps to assess selected claims for evaluation and management (E/M) services submitted by professional providers. Beginning on November 1, 2020, we will be using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.


Providers should report E/M services in accordance with the American Medical Association’s (AMA’s) CPT® Manual and the Centers for Medicare and Medicaid Services (CMS) guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The appropriate level of service is based primarily on 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 considered contributing factors. The coded service should reflect and not exceed that needed to manage the member’s condition(s).


Claims will be selected from providers who are identified as coding at a higher E/M level as compared to their peers with similar risk-adjusted members. The maximum level of service for E/M codes will be based on the complexity of the medical decision-making and reimbursed at the supported E/M code level and fee schedule rate. This initiative will not impact every level 4 or 5 E/M claim. Providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.


Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).


For questions on this program, please contact your Provider Solutions representative.



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August 2020 Anthem Provider News - Missouri