Major insurer reviewing, downgrading some E/M codes for outlier physicians

Anthem has launched a new correct coding initiative that will assess selected evaluation and management (E/M) claims from physicians who are outliers when it comes to billing. Anthem will use analytics to review whether coding on these claims aligns with national industry standards.

Claims will be selected from physicians who code at higher E/M levels compared to their peers with similar risk-adjusted patients. Prior to payment, Anthem will review the selected claims to determine whether the E/M code submitted is higher than the level supported. If so, Anthem may: 

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

The maximum level of service for E/M codes will be based on the complexity of the medical decision-making (MDM). Physicians who were billing based on total time and have codes downgraded can appeal and provide documentation referencing the time for the encounter.

Physicians who think their documentation supports payment for the originally submitted E/M level based on MDM can follow Anthem’s dispute resolution process. Anthem monitors dispute rates and overturn rates on an ongoing basis to determine if any physician is being disproportionately impacted.

When Anthem downgrades a claim to a lower level of service and payment, the coding on the physician’s claim will stay the same — only the payment will be adjusted. The explanation of benefits will say, "Evaluation and Management procedure code reduced based on diagnostic information. Disputes must include documentation."

Anthem is the second-largest private insurer in the United States, with about 40 million members. The company expects this initiative will impact a limited number of physicians in their network. It will not impact every high-level E/M claim, and physicians whose coding patterns revert to the norm will be removed from the program. Anthem will add and drop physicians every six months, when it conducts eligibility reviews.

If you have questions regarding this program, you can contact your local Anthem network consultant. To find your consultant, follow this link and select your state. You should then see a link to consultants in your area.  

— Brennan Cantrell, commercial health insurance strategist, and Erin Solis, manager of practice and payment, American Academy of Family Physicians