New reimbursement policy: Code and Clinical Editing Guidelines — Professional and Facility

Beginning with dates of service on or after October 1, 2025, the Code and Clinical Editing — Professional C‑09004 reimbursement policy will be retired, and a new reimbursement policy titled Code and Clinical Editing Guidelines — Professional and Facility C‑25002, which applies to both professional and facility providers, will be implemented.

Under the new Code and Clinical Editing Guidelines — Professional and Facility, the Health Plan applies the Code and Clinical Editing Guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits unless provider, state, or federal contracts and/or mandates indicate otherwise.

Standard correct coding guidelines apply, and providers should consult the CPT^®/HCPCS/ICD‑10 coding books for reference. These products increase the consistency of payment for providers by ensuring correct coding and billing practices and may automatically apply edits using the software’s editing logic. Code and Clinical Editing Guidelines CCEG consists of the following measures:

• Code editing software, CMS National Correct Coding Initiative (NCCI) edits, and Outpatient Code Edits (OCE)
• Code editing software is updated to conform to changes in coding standards
• National Correct Coding Initiative (NCCI) edits are updated according to CMS published updates: PTP (procedure to procedure)
• MUE (Medically Unlikely Edits)
• Clinical Criteria
• Claims processing platform
• Uniform Billing Editor

For more information, view this policy online. Visit https://anthem.com/provider and select a State. On the next screen, under the Resources heading, select Policies, Guidelines, and Manuals. Next, under the Reimbursement Policies heading, select Access policies.