Medicare AdvantageDocumentationHigh impact
[Ohio] Evaluation and Management Coding Review
CareSource·OH·Coding
Effective date
Jun 3, 2026
We identified it
May 9, 2026
Summary
CareSource will implement a level-of-care review program for all E&M coding effective June 3, 2026. Certified nurse coders will randomly and periodically review claims to ensure documentation supports the coded level. Claims found to lack supporting documentation will be downgraded to the appropriate level. Providers can dispute determinations through the claims dispute process with 30-day resolution.
Action Required
By June 3, 2026: Billing and clinical teams must audit current E&M documentation practices to ensure medical records consistently include pertinent facts of health and social history, physical exam findings, test results, assessment, and care plan for all encounter levels. Update provider templates and documentation standards to support medical necessity for each E&M level (99201-99215, 99291-99296, etc.). Train providers and coders on CareSource's documentation expectations to prevent level downgrades. Establish internal process to monitor for CareSource claim adjustments and prepare disputes with complete clinical documentation. Designate staff to contact CareSource Provider Services with questions using appropriate phone numbers (Marketplace: 1-833-230-2101; Medicaid/MyCare: 1-800-488-0134). Failure to maintain adequate documentation supporting coded levels will result in claim payment at lower supported levels.