Evaluation and management services correct coding (professional)

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 care providers. On September 1, 2021, we began using an analytic solution to facilitate a review of whether coding on these claims is aligned with national industry coding standards.

Care providers should report E/M services in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The coded service should reflect and not exceed the level needed to manage the member's condition(s).

Claims are selected from care providers who are 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 E/M code level submitted is higher than the E/M code level supported on the claim. If the E/M code level submitted is higher than the E/M code level supported on the claim, Anthem reserves the right to:

• Deny the claim and request resubmission of the claim with the appropriate E/M level.
• Pend the claim and request documentation supporting the E/M level billed.
• Adjust reimbursement to reflect the lower E/M level supported by the claim.

The maximum level of service for E/M codes is based on the complexity of the medical decision-making or time and is reimbursed at the supported E/M code level and fee schedule rate.

This initiative does not impact every level four or five E/M claim. Care providers whose coding patterns improve and are no longer identified as an outlier are eligible to be removed from the program.

Care providers who 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).

If you have questions about this program, contact your local network consultant. With your help, we can continually build towards a future of shared success.